A-Kidney donors over the age of 60 years without co morbidities .
B-Kidney donors age between 50-60 years with two co morbidities or more of the following ;
1-hypertension
2-Death from cerbrovascular accident .
3-Serum creatinine level more than 1.5 mg/dl
Selection criteria ;
1-For the donor, the Kidney Donor profile Index would be used to profile the donor kidney
2-For the recipient an older recipient would be selected to receive the ECD kidney.
3- Donor and recipient age matching is ethically fair and physiologically logic “old-for-old” program l.
4- Deceased donors aged65 years and older are allocated to un sensitized recipients aged 65 years and older .
5- Donor HLA-typing is not required, so allocation is done by using only ABO group matching, negative cross match, and a local allocation based on waiting time in order to keep cold ischemia time to a minimum.
KDPI;
A numerical measure estimated by calculating kidney donor risk index (KDRI) for a deceased donor
KDRI;
An estimation of relative risk of kidney graft failure from deceased donor compared to reference donor
lower KDRI has higher donor quality & graft survival
calculated by 10 donor factors: age, height, weight, ethnicity, history of DM or HTN, cause of death, serum creatinine, HCV status and donation after circulatory death
KDPI used for
matching candidates with longer estimated post transplant longevity (EPTS) of 20% or less with kidneys from donor with KDPI of 20% “longevity matching”
A predictive measure of donor quality,
show that some ECD kidneys may have good estimated quality and standard criteria donor may have a worse estimated quality
yes, preferred to be in elderly recipient as they have better patient survival after kidney transplant than those waitlisted on dialysis (1)
Reference ;
1- Wang Ziting et al. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian Journal of Urology.Vol 36. Issue 2 2020
2-F. K. Port, J. L. Bragg-Gresham, R. A. Metzger et al., “Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors,” Transplan-
tation, vol. 74, no. 9, pp. 1281–1286, 2002.
3- L. Fritsche, J. H ̈orstrup, K. Budde et al., “Old-for-old kidney allocation allows successful expansion of the donor and recipi- ent pool,” American Journal of Transplantation, vol. 3, no. 11, pp. 1434–1439, 2003.
4- W. H. Lim, S. Chang, S. Chadban et al., “Donor-recipient age matching improves years of graft function in deceased-donor kidney transplantation,” Nephrology Dialysis Transplantation, vol. 25, no. 9, pp. 3082–3089, 2010.
5-(1) Rose, C., Gill, J., & Gill, J. S. (2017). Association of kidney transplantation with survival in patients with long dialysis exposure. Clinical Journal of the American Society of Nephrology, 12(12), 2024-2031.
Abdullah Raoof
3 years ago
The expanded criteria donor (ECD) is
ü any donor over the age of 60,
ü or a donor over the age of 50 with two of the following:
o a history of high blood pressure,
o a creatinine (blood test that shows kidney function) greater than or equal to 1.5,
o or death resulting from a stroke.
Selection criteria : patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy
Alyaa Ali
3 years ago
Extended criteria donors
the use of ECD is increasing rapidly as a means of expanding the available donor pool
previously not considered for transplantation , they now represent about 25 % of donors
criteria :
age more than 60
age 50-59 and two or more of ( HTN, sCr more than 1.5 mg/dl , cerebrovascular cause of death)
super extended criteria donors : age more than 70
It has at least a 70% increased risk for failure within 2 years compared with standard criteria kidneys
they are offered only to those patients who have agreed to accept them , who have been informed of the risk
saja Mohammed
3 years ago
Expanded criteria donor: How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria? Please substantiate your answer
Source of donor kidney
LD, related or unrelated
DD, comparing old recipient with young one older recipient has less chance to receive a living donor kidney.
Living donor once available associated with better graft and patient survival, also allow for preemptive KTX which again associated with superior outcome.
Old recipient likely will get older donor age above 60 with shorter graft survival as compared to young donors .
Waiting list for donation increased to 14% waiting for more than 5 years in 2019and 40% of DD recipient waiting on dialysis more than 5 years . Those with blood group O, B, sensitized patient even waits longer Allocation DD program depend on the following:
EDC, expanded donor criteria, recipient characteristics, waiting list time
EDC expanded donor criteria::
Donor age above 60, or between 50-59 years with any of two
1-Creatinine > 1.5mg /dl,
2- cerebrovascular accident cause of death, or
3)-hypertension.
It has been anticipated that at 3 years, 70% of ECD kidneys with serum creatinine greater than 1.5 would be lost (1).
Systematic review of the literature from case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs conclude patients younger than 40 years or scheduled for retransplantaion should avoid the ECD kidney due to the poor graft survival while . Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long-expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy(2).
i would apply the EDC in selected type of recpients whom older than 50 , limited vascular access with long waiting dailysis time
1-Selective use of expanded criteria donors for renal transplantation with good results
S M Greenstein 1, G Schwartz, R Schechner, J Pullman, C Jackness, V Tellis, Transplant Proc
. 2006 Dec;38(10):3390-2.
2-A systematic review of kidney transplantation from expanded criteria donors
Julio Pascual 1, Javier Zamora, John D Pirsch, Am J Kidney Dis. 2008 Sep;52(3):553-86.
Balaji Kirushnan
3 years ago
Expanded Criteria donors:
any donor more than 60 years of age
Donor with >50 years with Hypertension, creatinine >1.5, death due to cerebrovascular cause
This definition was introduced by the Organ Procrurement and Transplantation Network (OPTN) in the year 2002. This definition does not include Donor after cardiac death
Yes I would offer it to CKD patients after careful selection based on the available epidemiological data as follows
Pros of ECD
the annual mortality rate in Hemodialysis patients is more than 20%
the rapidly growing transplant waitlist and subsequently increasing longer waiting time on HD, worsens overall patient survival
There has been definite survival advantage of ECD kidney transplant recipients over dialysis patients on waitlist in terms of overall mortality benefit
Cons of ECD
It has been documented that 70% risk of graft failure versus standard criteria donor
17% primary graft non function is reported as compared to SCD
38% of all the ECD kidneys were discarded versus 9% of all kidneys due to small kidneys
IT has been shown to have increased treatment cost and resource use due to increased hospitalization
The mortality in the peri operative period is higher in ECD kidney transplant recipients as compared to SCD recipients. This is due to increased episodes of acute rejection needed more hospital admissions and dialysis
There are definite subgroups which show significant survival advantage after ECD
patients more than 40 years and elderly
those with longer median waiting times on transplant
patients with diabetes or hypertension
those with lower immunological risk
dialysis patients with vascular access failure
dialysis patients whose life expectancy is lower than estimated waiting time for kidney transplantation
The survival advantage of ECD kidneys were more to older kidney recipients than younger ones probably due to shorter life expectancy in older recipients.
References:
Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis. 2008;52:553–586.
Ojo AO, Hanson JA, Meier-Kriesche H, Okechukwu CN, Wolfe RA, Leichtman AB, Agodoa LY, Kaplan B, Port FK. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol. 2001;12:589–597
Ahmed Omran
3 years ago
EXPANDED CITERIA DONOR (ECD)IS THE DONOR MORE THAN 0 YEARS OLD OR BETWEEN 50 TO 59 YEARS OLD AND HAVING 2 OF THE FOLLOWING:
1- DEATH RELATED TO CEREBROVASULAR ACCIDENT
2-HISTORY OF SYSTEMIC HYPERTENSION
3-TERMINAL SERUM CREATININE MORE THAN 1.5 MG/DL
ECD IS ASSOCIATED WITH 70% FAILURE COMPARED TO USING STANARD CRITERIA DONOR.ECD HAS BETTER SURVIVAL IN COMPARISON TO DIALYSIS PATIENTS.WITH STRATIFICATION OF DONOR AND RECIPIENT RISK,ALLOGRAFTS FROM ECD HAVE EXCELLENT SHORT TERM OUTCOMES.THIS APPROACH ACSHIEVED MAXIMAL UTILIZATION ,DECREASING KIDNEY DISCARD AND DEATH DURING WAITING .IN ADDITION,IT IMPROVED REHABILITATION ANDQUALITY OF LIFE WITH CONSIDERATION OF PERSONAL AUTONOMY.
DOCUMENTED INFORMED CONSENT MUST BE THERE WITH USING ECD ALLOGRAFT,INCLUDING THE RISK,CLEAR AWARENESS OF FAILURE POSSIBILITY WITH INFORMED PERCENTAGE.
REFERENCES:
B.RAMIREZ,CG & McCAULTY,J:CONTEMPORARY KIDNEY TRANSPLANTATION,SPRINGER:2018:76
DANOVITCH,GM: HANDBOOK OF KIDNEY TRANSPLANTATION sixth edition;94
Amer Hussein
3 years ago
Expanded Criteria Donor [ECD] is defined as
deceased donor >60 years
deceased donor > 50 years with hypertenion and a serum creatinine value >1.5mg/dL
deceased donor > 50 years with hypertension and death caused by a cerebrovascular accident [CVA]
deceased donor >50 years with serum creatinine >1.5mg/dL and death caused by a cerebrovascular accident [CVA]
patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy
deceased donor > 50 years with hypertenion and a serum creatinine value >1.5mg/dL
deceased donor > 50 years with hypertension and death caused by a cerebrovascular accident [CVA]
deceased donor >50 years with serum creatinine >1.5mg/dL and death caused by a cerebrovascular accident [CVA]
4 donor variables are used as criteria for being categorized as ECD: age of donor, serum creatinine value, cause of death and a history of hypertension
Yes i would offer an Expanded criteria donor kidney to my patients. Studies have shown that even though these kidneys are associated with some risk of earlier graft loss, they still function well: it is estimated that 8 out of 10 ECD kidneys would still be functioning at 1 year while 9 out of 10 Standard Criteria kidneys will be funtioning at 1 year. Renal transplant offers better quality of life and higher survival rates than remaining on dialysis or on the transplant wait list, so an ECD kidney transplant will do the patient better than waiting in the queue/ on dialys for a SCDonor.
Selection Criteria
for the donor, the Kidney Donor profile Index would be used to profile the donor kidney
for the recipient an older recipient would be selected to recieve the ECD kidney.
Wang Ziting et al. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian Journal of Urology.Vol 36. Issue 2 2020
Noble J et al. Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation. Front Immunol. 2020
For the donor, the Kidney Donor profile Index [KDPI] would be used to profile the donor kidney.
for the recipient the Estimated Post Transplant Survival Score [EPTS] is used to allocate the kidney. The EPTS is a formula that has four factors: age, presence of diabetes, history having had a prior solid organ transplant, and years on dialysis
The recipient with an EPTS score of </=20% gets a kidney with a low KDPI.
A Guide to Calculating and Interpreting the Estimated Post-Transplant Survival (EPTS) Score Used in the Kidney Allocation System (KAS) Updated: April 21, 2020. Organ Procuement and Transplantation Network
Mahmoud Rabie
3 years ago
The expanded criteria donors describes the suboptimal quality grafts from deceased donors including grafts from donors above 60 years old and donors or donors above 50 years with 2 of the followings: history of HTN, cerebrovascular cause of death, pre retrieval creatinine above 1.5 mg/dl.
Marginal donors is more broad term include deceased donors above 70 years with no risk factors or donors between 60-70 years with history of HTN, DM, proteinuria.
The use of expanded criteria or marginal donors is associated with relative risk of graft loss, however can be used in special situation to decrease the waiting list.
These type of grafts could be used in older patients with decreased expectancy of long life.
The expanded criteria donor (ECD) is an effort to increase the donor pool. ECD kidneys are used to expand the number of deceased-donor kidney transplants, particularly for elderly recipients.it has two criteria
1. donor over the age of 60.
2 donor over the age of 50 with two of the following: a history of high blood pressure, a creatinine (blood test that shows kidney function) greater than or equal to 1..5, or death resulting from a stroke..
I would offer ECD to some groups of ckd patient specially old age . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4801786/#!po=14.7321
Nasrin Esfandiar
3 years ago
With increasing need to extend donor pool, OPTN defined marginal kidneys and then ECD in 2002. Deceased donors with age equal or more than sixty years old and donor between 50 -59 with more at least two of following condition were considered as ECD: patients with previous history of HTN, serum creatinine equal or more than 1.5 mg/dl, CVA as cause of death. Although outcome of standard citeria transplantation is better than ECD transplantation but is still better than dialysis patients. So this would be a good option in selected conditions. Quality of these grafts can be assessed using kidney biopsy parameters before transplantation.
We consider ECD donors for the following candidates in our center (Labafinezhad Hospital):
1- Recipients of the same age.
2- Recipients older than 40 years with diabetes.
3- Recipients older than 40 years are candidates for standard criteria transplantation.
We don’t use DCD donors in our center.
References:
1. Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-125.
2. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA. 2005;294(21):2726-2733
3.Pascual, J., Zamora, J., & Pirsch, J. D. (2008). A Systematic Review of Kidney Transplantation From Expanded Criteria Donors. American Journal of Kidney Diseases, 52(3).
4. Dedinská I, Palkoci B, Vojtko M, Osinová D, Lajčiaková M. Experiences With Expanded Criteria Donors: 10-Year Analysis of the Martin, Slovakia Transplant Center. Exp Clin Transplant. 2019 Feb;17(1):6-10.
AMAL Anan
3 years ago
The expanded criteria donor (ECD) is any donor over the age of 60, or a donor over the age of 50 with two of the following:
1- a history of high blood pressure.
2- a creatinine greater than or equal to 1.5 mg/dl.
3- death resulting from stroke.
The survival benefits seen in recipients of marginal kidney transplants are inferior compared with those in recipients of standard criteria donor kidneys, but significantly better than in those remaining on hemodialysis
Although advanced age is not recognized as a contraindication to kidney transplantation, KT in the elderly remains challenging and a careful selection of candidates, taking into account all the comorbidities being mandatory.
KDPI is a percentage score that provides how long the kidney is likely to function when compared to other kidneys.
KDPI depends on :
Age.
Height and weight.
History of hypertension.
History of diabetes.
Cause of death.
Serum creatinine.
HCV status.
Donor meets DCD criteria.
A KDPI score of 20% means that the kidney is likely to function longer than 80% of other available kidneys. A KDPI score of 60% means that the kidney is likely to function longer than 40% of other available kidneys .
EPTS depends on :
Age.
Current diabetes status.
Numbers of previous transplants
Receiving chronic dialysis.
The EPTS score estimates how long the candidate will need a functioning kidney transplant when compared with other candidates. A person with an EPTS score of 20% is likely to need a kidney longerlive longer than 80% of other candidates. Someone with an EPTS score of 60% will likely need a kidney longer than 40% of other peoples.
KDPI scores ≥ 85% are similar to the previously designated “ECD” kidneys and like “ECD” kidneys, are deemed to be viable for transplant in the appropriate recipients , typically older patients, those who cannot withstand dialysis for an extended period of time, and those recipients with high EPTS score. Additionally, KDPI ≥ 85% are made available to a wider geographic region than all other kidneys in an attempt to locate a suitable candidate in the quickest manner possible. Modeling of the KAS predicted that the tandem use of KDPI and EPTS would produce a significant rise in the “average projected median lifespan after transplantation,” as well as the “time with a functional allograft.
References:
Gebel H, Kasiske B, Gustafson S, et al. Allocating deceased donor kidneys to candidates with high panel reactive antibodies. Clin J Am
Soc Nephrol 2016;11:505–511.
Hall E, Massie A, Wang J, et al. Effect of eliminating priority points for HLA-B matching on racial disparities in kidney transplant rates.
Am J Kidney Dis 2011;58:813–816.
Leichtman A. Improving the allocation system for deceased-donor kidneys. N Engl J Med 2011;364:1287–1289. 77.
Last edited 3 years ago by AMAL Anan
Ahmed Faisal
3 years ago
☆ Marginal donor (expanded criteria donor) is any donor who
• > 60 years or
• 50-59 years with two other risk factors
. history of hypertension,
. death due to cerebrovascular event
. raised serum creatinine at retrieval > 1.5
mg/dl
* Danovitch
☆ Marginal kidney may be obtained from
• Marginal donors (as above)
• standard donors but with
. complex anomalies of blood supply (2 or
more arteries which may need to double
anastomosis).
. complex anomalies of the excreted pathway
(separated 2 ureters).
. observable parynchemal disease (as area of
macroscopic sclerosis).
* Paride De Rosa, Giovanna Muscogiuri, Gerardo Sarno, “Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients”, International Scholarly Research Notices, vol. 2013, Article ID 301025, 8 pages, 2013. https://doi.org/10.5402/2013/301025
———————–
Kidney Allocation System (KAS) was created in 2014 and has great achievements in shortening of waiting list of patients on dialysis and giving priority of transplantation of highly sensitized patients.
☆ Selection criteria is based on
• Donor —–> Kidney Donor Profile Index (KDPI).
• Recipient —–> Expected Post Transplant Survival (EPTS)
score
☆ KDPI gives idea about quality of donor kidney by using ten factors in donor to estimate the risk of graft failure after kidney transplantation (age, height, weight, ethnicity/race, history of hypertension, history of diabetes, serum creatinine:(mg/dL), HCV Status, donor meets DCD criteria?)
Range: 0 -100
Lower KDPI means longer graft survival
☆ EPTS is estimation of longevity of the graft by using four factors in recipient (age, time on dialysis, past history of any solid organ transplantation, diabetes status).
Range: 0 -100
Lower EPTS means longer years of graft function.
The kidneys with low KDPI values (20% or less) will be offered to candidates with the high score of EPTS (top 20 %)
* Israni, Ajay K., et al. “New National Allocation Policy for Deceased Donor Kidneys in the United States and Possible Effect on Patient Outcomes.” Journal of the American Society of Nephrology (2014): ASN-2013070784.
●●●Marginal cadaveric kidney donors can be
defined as: all donors older than 60 years, donors older than 50 years with any of the following criteria:
1- Hypertension.
2- cerebro-vascular cause of brain death.
3- pre-retrieval serum creatinine (SCr) level > 1.5 mg/dl, with a degree of glomerulosclerosis >15% and prolonged cold ischemia.
●● YES, i will offer it to my patients.
There is enough published evidence of its better outcome than waitlisted patients.
The focus is on finding various ways to improve the outcome of such marginal grafts.
In a consensus statement, an international panel of pathologists presented a methodology to assess the marginal kidneys based on the viable nephrons to guide about single or dual transplantation or discard the organ.
●● SELECTION CRITERIA according to this panel :
This panel suggested a biopsy based scoring system for kidneys, with scores ranging from a minimum of :
0 (indicating the absence of renal lesions) to a
maximum of 12 (indicating the presence of marked changes in the renal parenchyma).
●● Kidneys with a score of 3 or lower were
predicted to contain enough viable nephrons for single transplants.
Those with a score of 4, 5 or 6 could be used as dual transplants, on the assumption that the sum of the viable nephrons in the two kidneys approached the number in one ideal kidney.
Kidneys with a score of 7 or greater were discarded, since it was assumed that they would not deliver sufficient number of nephrons, even for even dual transplantation.
●● REFERENCES
1- 48. Remuzzi G, Grinyo J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol. 1999;10:2591–8. [PubMed] [Google Scholar] [Ref list].
2- 51. Pirani CL, Salinas-Madrigal L. Evalua-tion of percutaneous renal biopsy. In: Sommers SC, editor. Kidney pathology de-cennial, 1966–1975. New York: Appleton-Century-Crofts; 1975. [Google Scholar] [Ref list]
3- 52. Pirani CL. Evaluation of kidney biopsy specimens. In: Tisher CC, Brenner BM, editors. Renal pathology, with clinical and functional correlations. Philadelphia: JB Lippincott; 1994. pp. 85–115. [Google Scholar] [Ref list]
Last edited 3 years ago by Mina Meshreky
Fatima AlTaher
3 years ago
Marginal donor or expanded criteria donor
refers to a less favorable deceased donor who previously would be rejected , but due to shortage in donor pool , these donors now can be used for special patients such as elderly and patients with short life expectancy.(1)
Diagnostic chriteria of ECD
1- Age > 60 y without comorbidity
2- Age (50 -59) with 2 or more
Hypertention
Death from CVA
Last premortem S Cr 1.5 mg/dl.
1- Maggiore, U., & Cravedi, P. (2014). The marginal kidney donor. Current opinion in organ transplantation, 19(4), 372-380.
Tahani Hadi
3 years ago
Marginal kidney or expanded criteria donor (ECD) means that when the donor is above 60 years old or above 50 with history of hypertension or his serum creatinine greater than or equal to 1.5 mg/dl or when the donor died due to cerebrovascular cause.
ECD helps the patient to decrease waiting time till transplant but the recipient should be informed and should have his permission because it has a risk of earlier graft loss than the ideal kidney or standar criteria of donor but the exact risk is unknown.
ECD still remains superior or better than keeping the patient on dialysis but it depends on recipient age and survival advantages or disadvantages from the transplantation.
Absence of living donor make ECD is good choice especially for those patients who are old age on dialysis, also it’s used in diabetic and /or hypertensive patients .
In summary ECD is useful for old age group patients on waiting list and old age patients with HTN and / or DM with poor survival rate but they achieve great benefits after ECD transplant compared to those patients remaining on dialysis.
Many studies showed that kidneys from ECD are more immunogenic and that affect graft survival and increase incidence of rejection which depend mainly on recipient age and type of immunosuppressive regimen.
Most recipient from ECD are old age so it’s important to focus on induction and maintenance of immunosuppressive medications and to take care of high risk of infection and other side effects.
Nazik Mahmoud
3 years ago
Expanded criteria donor or marginal kidney is a term to describe the quality of deceased donor kidneys it include:
Donor older than 60 years or aged 50 to 59 with two additional risk factors:
History of hypertension
Death as a-result of cerebrovascular accident
Elevated serum creatinine more than 1.5mg/dl
It offered for patients who had agreed to accept them and informed about the risk of failing is 70% in the next 2 years
The selection criteria would be for the desperate patients who waited for long time and had complications in dialysis
Ahmed Abdalla
3 years ago
Due to the increased demand in transplantable organs, the gap between kidney graft and supply grows. The organ shortage continues despite the fact that surgeons have liberalized their acceptance criteria for suitable deceased donor organs, have exploited the use of ABO-incompatible and marginal ‘expanded criteria donors (ECD)’. However, kidneys from ECD donors come with their relative risk of graft failure of 1.7 compared with a reference group so it is offered only to those who accept that these kidneys are more likely to fail. Therefore, selection of kidneys from ECD donors remains extremely important to guarantee an adequate kidney function and graft survival for long-term. Some ECD donor kidneys are not accepted by many centers due to their extreme age and additional risk factors such as hypertension, diabetes mellitus of the donor. A comprehensive assessment of the ECD kidney is mandatory and long-term graft survival and kidney function need to be assure.
Expanded criteria donors ( ECD) defined as deceased donor who is more than 60 years old or 50-59 years old in addition to 2 of the followings:
history of hypertension
death due to cerebrovascular accident
elevated terminal serum creatinine
. The quality of the available kidney for transplantation can be estimated through calculating the kidney donor profile index ( KDPI). factors used to estimate KDPI are:
age
height & weight
ethnicity
history of hypertension
history of diabetes
cause of death
serum creatinine
HCV status
donor meets DCD criteria
The lower KDPI score associated with longer graft function. So if the patient do not has a live donor and he accepted to receive an expanded donor criteria and the available organ is of a lower KDPI score and the recipient is of low expected post transplant survival, an ECD can be used for him.:
file:///C:/Users/hp/AppData/Local/Temp/msohtmlclip1/01/clip_image001.jpg
Older kidneys can be used in older recipients, the so-called “old-for-old” program. This form of age matching is ethically fair. According to this the Eurotransplant Senior Program (ESP), a well-established old-for-old allocation program existed since 1999 ,where deceased donors aged 65 years and older are allocated to unsensitized recipients aged 65 years and older, so HLA-typing is not required, allocation is done by using only ABO matching, negative crossmatch,and a local allocation based on waiting time in order to minimize cold ischemia time .
the Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney.
These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death.
lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function.
example: KDPI of 20% will have a longer function than 80% of recovered kidney.
on average, a kidney with KDPI<20% lasts 11,5 years
a kidney with KDPI >20% TO <85 % lasts 9 years
a kidney with KDPI > 85% lasts 5,5 years
Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
Thank you, Ahmed
The whole transplant community and not Surgeons only liberalized their acceptance criteria for suitable deceased donor organs.
You raised an important issue of (Old for Old) transplantation.
MICHAEL Farag
3 years ago
expanded criteria donorECD kidneys are those either from a brain-dead donor ≥ 60 years of age, or a donor 50 to 59 years of age with at least two of the following features: History of hypertension, terminal serum creatinine > 1.5 mg/dL (133 mmol/L), or cerebrovascular cause of death. These criteria for the definition of ECD were based on the presence of variables that increased the risk for graft failure by 70% (relative hazard ratio 1.70) compared with a standard criteria donor (SCD) kidney. Kidney transplants coming from donation after cardiac death (DCD) are not included in this definition. SCD was defined as a donor who does not meet the criteria for DCD or ECD
The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool.
Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies.
**Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression? Vassilis Filiopoulos, John N Boletis,World J Transplant. 2016 Mar 24; 6(1): 103–114.
for me, I don’t prefer ECD to my CKD patient unless dialysis has life-threatening complications/contraindications or if the patient accepts the risks of transplantation of ECD especially high immunosuppressive medications after full explanation
Heba Wagdy
3 years ago
The term marginal criteria donor replaced the term expanded criteria donor (ECD)
which describe kidney from deceased donor
age >60 years
or age 50-59 years with 2 more risk factors including (HTN, death due to cerebrovascular accident or terminal serum creatinine >1.5mg/dl)
KDPI
A numerical measure estimated by calculating kidney donor risk index (KDRI) for a deceased donor
KDRI
An estimation of relative risk of kidney graft failure from deceased donor compared to reference donor
lower KDRI has higher donor quality & graft survival
calculated by 10 donor factors: age, height, weight, ethnicity, history of DM or HTN, cause of death, serum creatinine, HCV status and donation after circulatory death
KDPI used for
matching candidates with longer estimated post transplant longevity (EPTS) of 20% or less with kidneys from donor with KDPI of 20% “longevity matching”
A predictive measure of donor quality,
show that some ECD kidneys may have good estimated quality and standard criteria donor may have a worse estimated quality
yes, preferred to be in elderly recipient as they have better patient survival after kidney transplant than those waitlisted on dialysis (1)
(1) Rose, C., Gill, J., & Gill, J. S. (2017). Association of kidney transplantation with survival in patients with long dialysis exposure. Clinical Journal of the American Society of Nephrology, 12(12), 2024-2031.
Thank you all for your fruitful contribution. Feel free to add to it and press “complete”.
Ramy Elshahat
3 years ago
what a great topic to dicuss
lets think clinically and critically
you have patient need a kidney and you have to decide a lot of issues
you have scale use four items which is age/hypertension/s.creatinine/cerebrovascular stroke……is this enough to decide this graft is bad???
KDPI numerical measure that combine ten factors which is (age,height,weight,ethnicity,hx of hypertension,hx of DM,cause of death,serum creatinine,hepatitis c and donation after circulatory death
I think ten module is better than four
ok….to how strong the association between KDPI and graft survival
the predictive power is moderate
what that mean>>>>that mean you should not certain number equal good graft and below it is usually bad and this scale has a lot of limitation like(duration of hypertension,duration of diabetis,state of virus c activity,smoking,malignancy,other infections other than virus c and gender)
so should I neglect it
I think it can be used to evaluate relative risk in relation to reference population
also and that was its primary purpose was for “longevity matching” concept into kidney allocation system>>>>candidate with longer estimated post transplant longevity receive priority for graft KDPI of 20% and vice verca
can KDPI expect graft survival>>>>> I think graft survival not related only for the donor criteria but also the recipient but there is moderate predictive power as I mentioned before
finally I should also comment on is older patients is candidate for kidney with KDPI more than 80%
i think the answer is yes and no
yes because as I mentioned longevity matching
no if he has better opportunity if he is on top of the list and he is completely fit and he possible will life longer
so individualize is my answer
Thanks, Ramy for your reply This is a great reflection, but you need to follow the academic writing style. The answer should be structured in heading and subheadings. Also, there is a lot of “I think” in your reply. You need to substantiate your answer with evidence.
I admire the reflection and writing in your own words.
The Scientific Registry of Transplant Recipients define ECD kidneys as: (1)kidneys from deceased donors aged 60 years or above, or
(2) donors aged 50–59 years with at least two of the
following
cerebrovascular accident as the cause of death, terminal or
serum creatinine >1.5 mg/dL or
a history of hypertension.
The designation of SCDs or ECD is binary, but in reality,
there is a continuum.So to fine-tune the SCD/ECD criteria kidney donor profile index is used which is a numerical value.The Kidney Donor Risk Index (KDRI) for a deceased donor is used to calculate the KDPI.The Kidney Donor Risk Index (KDRI) is a calculation that compares the relative risk of post transplant kidney graft failure from a deceased donor’s to a reference donor. In the original KDRI report, the reference donor was 40 years old, non-diabetic. To create the scaled (or “normalised”) form of KDRI presented in DonorNet®, the median (50th percentile) donor was used as the reference donor.
The following donor characteristics are used to calculate the KDRI:
Age
History of Diabetes
Height
Cause of Death
Weight
Serum Creatinine
Ethnicity
Hepatitis C Virus (HCV) Status, from serological or NAT testing
History of Hypertension
Donation after Circulatory Death (DCD) Status
Lower KDPI is associated with longer predicted survival, while higher
KDPI (more than 80) is associated with shorter predicted
survival for the aggregate population.
A Guide to Calculating and Interpreting the Kidney Donor Profle Index (KDPI) Updated: March 23, 2020
Expanded criteria donors in deceased donor kidney
transplantation – An Asian perspective
Ziting Wang*, Pradeep Durai, Ho Yee Tiong
selection criteria –
Remuzzi et al used histology-based selection criteria to assess the quality of ECD kidneys and determine whether they should be implanted single or dual. The kidneys of a donor were obtained, and histopathological examinations were performed.The severity of chronic changes was used to assign a score. Changes in four separate renal tissue components,
vessels
glomeruli
tubules
connective tissue
were scored separately from 0 to 3.
Kidneys with global scores of 0–3 were implanted singly, and
those with scores of 4–6 were considered for dual implants;
those with a score of seven or greater were discarded.
Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective-Ziting Wang, Pradeep Durai, Ho Yee Tiong
For explant biopsy, Vathsala compared the efficacy of KDPI with the Remuzzi score and found that the Remuzzi score was superior in prognosticating graft results in the short term.For improved risk stratification, they concluded that explant biopsies should be performed frequently for patients with KDRI > 1.1.
Vathsala A. Explant biopsy and Remuzzi scoring outperforms Kidney
Donor Profile Index (KDPI) in selection of extended criteria donor
kidneys for single implant. Transplantation 2018;102:1200‑2
Extended Criteria Living Donors should consider donor age, GFR, BMI, impaired glucose tolerance and smoking history.
in the study Donors were divided in two groups: donors without risk factors (RF) and donors with at least one RF. RF were defined as age over 60 years, arterial hypertension, active nicotine abuse and BMI over 30kg/m2.Allografts from high-risk donors had poorer graft function in the first year, according to the findings of the study. Only those beyond the age of 60 had a reduction in the survival of grafts As a result an expansion of criterion for living kidney donors could help to improve the current situation of organ shortage. A thorough preoperative evaluation and allocation of donors and receipients is absolute essential.
Extended Criteria Donors in Living Kidney Transplantation Including Donor Age, Smoking,Hypertension and BMI-Henning Plage, Poline Pielka,Lutz Liefeldt, Klemens Budde,Jan Ebbing, Nesrin Sugünes,Kurt Miller,Hannes Cash,Anna Bichmann, Arne Sattler, Katja Kotsch,
Frank Friedersdorff.
Jamila Elamouri
3 years ago
Expanded Criteria Donor (ECD) It tool was developed to use kidneys with suboptimal characters, in an attempt to increase the availability of donor pool. This includes kidneys from donors with:
1- Age ≥ 60 years
2- Age 50 – 59 with at least 2 of the following:
· History of hypertension
· S.cr > 1.5 mg/dl
· Cerebrovascular accident as the cause of death.
Kidney donor profile index (KDPI): Because the quality of deceased donor kidney is an important issue in transplantation, KDPI had been done to assess it, to decide whether to discard the kidney, and to predict the outcome of the allograft after transplanting it. To determine KDPI, first, need to calculate the donor’s kidney donor risk index donor characters used to calculate the KDRI are:
· age,
· H/O DM,
· Height,
· weight.
· Cause of death,
· s cr,
· ethnicity,
· HCV status,
· H/O hypertension,
· donation after circulatory death status (DCD)
KDPI is a simple map of the KDRI, a measure of relative risk to a cumulative percentage scale. Take values between 0% – 100%. A donor with a KDPI of 0% has less than all donors in the reference population. KDPI of 20% means the donor has a KDRI exceeding at least 19% and at most 20% of all donors in the reference population. In general, a donor with a KDPI of X % means that the donor’s KDRI is more than (X─1)%, but not more than X% of all donors in the reference population. It is displayed in donor Net
· Yes, I will offer for older > 60 yrs ECD has inferior outcomes compared to the kidney from donors that do not meet the ECD definition. They can be carefully utilized for selected patients example older patients with a long waiting time of 4 or more years as they show better survival and quality of life than dialysis.
References:
1. Park WY, Kim JH, Ko EJ, Min J-W, Ban TH, Yoon H-E, et al. Impact of Kidney Donor Profile Index Scores on Post-Transplant Clinical Outcomes Between Elderly and Young Recipients, A Multicenter Cohort Study. Sci Rep [Internet]. 2020 Apr 24;10(1):7009. Available from: https://pubmed.ncbi.nlm.nih.gov/32332846
2. Wang Z, Durai P, Tiong HY. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian J Urol [Internet]. 2020/04/07. 2020;36(2):89–94. Available from: https://pubmed.ncbi.nlm.nih.gov/32549658
3. Graft M, Estimates S, Donor D, During AT. A Guide to Calculating and Interpreting the Kidney Donor Profile Index ( KDPI ) Figure 1 . Kaplan − Meier Graft Survival Estimates for Adult, Deceased Donor, Kidney − Alone Transplants During 2008 − 2018 by KDPI. 2020;1–11.
Mujtaba Zuhair
3 years ago
Expanded criteria donor in deceased donation is defined as those with age more than 60 years or age more than 50 years with 2 additional risk factors : terminal serum creatinine more than 1.5 mg/dl , history of hypertension, cerebrovascular cause of death.
Standard criteria donor SCD in deceased donation are those deceased donors who did not meet the criteria for ECD.
The expanded criteria donor is associated with 70% increased risk of graft loss when compared to SCD. But the risk may decrease is certain high risk patient characteristics. For example, in elderly (age>65 years) , the the life expectancy with ECD was 5.3 years compared with 505 years for SCD.
Elderly patients > 65 years, diabetics , long time on waiting list , patients with high PRA, may benefit from ECD , to decrease their time on waiting list, since survival in these patients will not not differ so much if they receive ECD or SCD.
References:
(1) Jesse D. Schold and Herwig-Ulf Meier-Kriesche Which Renal Transplant Candidates Should Accept Marginal Kidneys in Exchange for a Shorter Waiting Time on Dialysis?Clin J Am Soc Nephrol 1: 532–538, 2006. doi: 10.2215/CJN.01130905.
(2) Maggie K.M. Ma, Wai H. Lim, Jonathan C. Craig, Graeme R. Russ, Jeremy R. Chapman, and Germaine Wong Mortality among Younger and Older Recipients of
Kidney Transplants from Expanded Criteria Donors
Compared with Standard Criteria Donors Clin J Am Soc Nephrol 11: 128–136, 2016. doi: 10.2215/CJN.03760415
Theepa Mariamutu
3 years ago
Criteria of ECD of deceased donor:
Age >60.
Age 50 – 59 with two or more of the following:
· High blood pressure.
· S. Cr>133 μ mol/L (1.5mg/dL).
· Cerebrovascular cause of death
I will offer marginal kidneys to those who has been in long waiting list, no suitable living donor, aged more than 50 and whom has comorbidies. I would preserve SCD for those who are young and better QoL. SCD generally better in graft and patients survival compared to those ECD. The benefits of ECD in those over 65 still debatable, which need more studies to prove. ECD vs SCD benefits also differs between Europe and USA where Europe has more or less narrow differences in patient -graft survival , patient survival, death censored graft survival between SCD and ECD. but USA showed vast differences among SCD and ECD.
Reference(s)
Querard, A., Foucher, Y., Combescure, C., Dantan, E., Larmet, D., Lorent, M., Pouteau, L., Giral, M. and Gillaizeau, F., 2016. Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis. Transplant International, 29(4), pp.403-415.
Hellemans, R., Kramer, A., De Meester, J., Collart, F., Kuypers, D., Jadoul, M., Van Laecke, S., Le Moine, A., Krzesinski, J., Wissing, K., Luyckx, K., van Meel, M., de Vries, E., Tieken, I., Vogelaar, S., Samuel, U., Abramowicz, D., Stel, V. and Jager, K., 2021. Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort. Nephrology Dialysis Transplantation, 36(5), pp.918-926.
This Belgium cohort ( Eurotransplant waitlist) analysed the long term outcome after renal transplantation vs dialysis
– Showed that even at the age more than 65 had a survival benefit with transplantation at least with SCD kidney
– Outcome less favourable when older patients with ECD kidneys.
– Did not showed a statistically significant difference in survival between older patients received and ECD kidney vs those remaining on dialysis – but there is a trend favouring ECD
– Found that ECD transplantation was associated with a higher mortality risk post transplantation compared SCD – may result from an increased risk of poor or delayed graft function
–
Rao PS, Merion RM, Ashby VB et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipient
– Found that survival benefit from transplantation even if the recipient is more than 70 with ECD.
Gill JS, Schaeffner E, Chadban S et al. Quantification of the early risk of death in elderly kidney transplant recipients. Am J Transplant 2013; 13: 427–432
– The risk different according to comorbidities and donor type.
Two studies in France and Catalonia
1. savoye e, tamarelle d, chalem y et al. survival benefits of kidney trans- plantation with expanded criteria deceased donors in patients aged 60 years and over. transplantation 2007; 84: 1618–1624
2. LloverasJ,ArcosE,ComasJetal.Apairedsurvivalanalysiscomparinghe- modialysis and kidney transplantation from deceased elderly donors older than 65 years. Transplantation 2015; 99: 991–996
– Showed survival benefit with transplantation even in older recipient even with the use of ECD
Study by Peters-SengersH,BergerSP,Heemskerk Metal.Stretchingthelimits Of renal transplantation in elderly recipients of grafts from elderly deceased donors. J Am Soc Nephrol 2017; 28: 621–631
– Showed no benefit in survival in patient with >65 transplanted with older donor
– Showed no difference in 5 year survival between DBD or DCD even in patient >65 received from >65 donor
Its not easy to interpret those results due to heterogeneity in population and varying methodology.
Last edited 3 years ago by Theepa Mariamutu
Esmat MD
3 years ago
Expanded criteria donor (ECD) is an old lexicon for marginal kidney that is defined as a deceased donor older than 60 years or aged 50-59 years with two additional risk factors consisting of a history of hypertension, death as a result of cerebrovascular accident or an elevated serum Cr. ECD is related to lower graft survival than SCD. For allocation patients for kidney transplantation, it is better to utilize Kidney Donor Profile Index (KDPI) and Expected Post Transplant Survival (EPTS). KDPI score is an estimation of kidney allograft quality and factors determining it are age, height and weight, ethnicity/race, history of diabetes, cause of death, serum Cr, DCD. In contrast, the EPTS score estimates how long the candidate will need a functioning kidney and it’s determining factors are age, current diabetes status, number of previous transplants and receiving chronic dialysis. A KDPI of 20% means that the kidney will have function longer than other 80% of available kidneys for donation and a EPTS score of 20% means that the candidate needs a functioning kidney longer than 80% of other candidates. It is important to match KDPI score and EPTS score for allocation of patient for transplantation. For example, kidneys with a KDPI score ≤ 20% first will be offered to patients with an EPTS score ≤ 20%. KDPI scores ≥ 85% are similar to ECD and should be used for older patients, those who cannot stand on dialysis for an extended duration and those with high EPTS.
Mohamed Fouad
3 years ago
Extended Criteria Donors in Living Kidney Transplantation Including Donor Age, Smoking, Hypertension and BMI There was a retrospective single-centre study analysed 158 patients with living kidney transplants performed between February 2006 and June 2012. They investigated the influence of donor risk factors (RF) including body mass index over 30 kg/m2, age > 60 years, active nicotine abuse and arterial hypertension on postoperative kidney function with focus on the recipients. This was measured for long-term survival and glomerular filtration rate (GFR) in a 5-year follow-up. The result was out of 158 living donors, 84 donors were identified to have no risk factors, whereas 74 donors had at least one risk factor. They noted a significant higher delayed graft function (p=0.042) in the first 7 days after transplantation, as well as lower GFR of recipients of allografts with risk factors in the first year after transplantation.In long-term results, there was no significant difference in the functional outcome (graft function, recipient and graft survival) between recipients receiving kidneys from donors with no and at least one risk factors. In the adjusted analysis of subgroups of different risk factors, recipients of donors with “age over 60 years” at time of transplantation had a decreased transplant survival (p=0.014). In Conclusion: Eexpanded criteria living donors (ECLDs), could improve access for many patients diagnosed with ESKD. ECLDs should consider donor age, GFR, BMI, impaired glucose tolerance and smoking history. Moreover, in living donors the kidneys vascular supply could influence recipients’ outcome. A detailed evaluation of these risk factors and comorbidities is therefore essential to maintain donor safety as the mentioned risk factor are associated with increased rates of perioperative nephrectomy complications.
The authors: Henning Plage,1 Poline Pielka,1 Lutz Liefeldt,2 Klemens Budde,2 Jan Ebbing,3 Nesrin Sugünes,1 Kurt Miller,1 Hannes Cash,1 Anna Bichmann,4 Arne Sattler,5 Katja Kotsch,5 Frank Friedersdorff1 DOIhttps://doi.org/10.2147/TCRM.S256962 published August 2020
Reem Younis
3 years ago
marginal kidney (ECD )comes from a deceased donor older than 60years or aged 50-59 years with 2 additional risk factors including a history of hypertension, death as a result of cerebrovascular accident, or elevated serum creatinine. It increases the donor pool.ECD is about 15% of deceased donors and has a 70% increased risk of failing within 2 years is compared with a standard criteria donor kidney. It is commonly offered for an older patient with a short survival time and cannot withstand dialysis for an extended period.
Types of marginal donors:
1. complex living donor
2. Non –heart beating donor
3. deceased or cadaveric donor.
Kidney donor profile index (KDPI): the variables used to determine it:
Age Height and weight
Ethnicity/race History of hypertension
History of diabetes Cause of death
Serum creatinine HCV status
Donors meet DCD criteria
Expected Post-Transplant Survival (EPST) factors:
Age Current diabetes status
Number of previous transplants Receiving chronic dialysis
KDPI scores≥85 are similar to ECD and appear to be viable for transplant inappropriate recipients and those recipients with high ESPT scores.
Gopalakrishnan et al.: Marginal kidney donor (http://www.indianjurol.com on Thursday, January 14, 2016, IP: 75.101.1)
Danovitch G.M handbook of kidney transplantation sixth edition.
MOHAMMED GAFAR medi913911@gmail.com
3 years ago
since art of transplantion had started, scientist are searching to expand the pool of candidates.and they started to think how can we utilize descased kidnies, in fact that the new era of immnosuprresion with cnis and antimetaboiltes had raisen the possibilties of such sucess.
IN 2014 KAS (KIDNEY ALLOCATION SYSTEM) INTRODUCED IN PRACTICE KDPI, , AND ALSO EPTS (EXPECTED POST TRANSPLANT SURVIVAL), THE FIRTS FOR THE DONOR AND THE LATER FOR THE RECPIENT.
KDPI (kidney donor profile index) was the scheme that they relay on to select such donors , and it depends on alot of factors like (age , height, weight,htn, diabetes, cause of death, serum creat, hcv status ).
high kdpi means poor kidney function.in another treminology if the donor has kdpi of 60% that means that the kidney is likely to function longer than 40% of other avilable kidnies .
EPTS , IT HAS MANY FACTORS LIKE(AGE , CURRENT DM, NUMBER OF PREVOIUS TRANSPLANT, IS HE ON CHRONIC DIALYSIS OR NOT.
THE LOWER THE EPTS THE HIGHER POST TRANSPLANT SURVIVAL.
MARGINAL KIDNEY DONORS OR OLD TERMINOLOGY AS ECD KIDNEIES, WHAT DOSE IT MEAN? IT MEANS DONATION FROM DECASED KDINEY DONOR WITH AGE MORE THAN 60 OR AGE BETWEEN 50-59 WITH TWO RISKFACTORS HTN OR DAETH DUE TO CERBRO VASCULAR STOKE OR ELEVATED TERMINAL SERUM CREAT MORE THAN 1.9.
in fact we have to ask many questions befor offering this kidney to a ckd pt .
1-what is his age
2-cause of his ckd
3-comorbidites htn, dm, ihd
4-bmi
5-tranplanted befor or not
6-what is his cPRA
all this questions will let us know what is suitable for him.
.
SO , IF THE DONOR HAS A HIGH KDPI WE CAN OFFER IT TO RECIPENT WITH HIGH EPTS .AND VICE VESRA, THIS IS A SIMPLE WAY TO UNDERSTAN HOW DECESED KIDNIES ARE ALLOCATED.
Mohamed Essmat
3 years ago
Regarding the definition of marginal kidney donor , the exact definition isn’t set yet , i believe it entails those who were not eligible or those who where instantly rejected in the past , those of old age 65-70 years old , those with HTN , females in the child bearing period , GFR of 60-90 ml/min/1.72m , Albumin excretion ratio of 30-100mg/day , obesity BMI 35-40 KG/m , and afraid to say that diabetes as well although written in the absolute contraindications of the OPTN , but the European society and the British transplantation society rarely include thorough ex. and investigations about the risks , comorbidities and survival of the graft . Extended criteria donor include the “Grey zone ” are of potentiality of the donor , before this term wasn’t actually present but recently the need for more donors and the waiting lists of the recipients encouraged experts and health care individuals to include some of those donors on the edge of the “NO” for the good , Provided that should be based on studies , through history, examination , thorough counseling and care about the risks for the donor.
Yes, i believe we can adopt the idea of marginal donors through “individualization”.
*HTN if controlled less than 140/90 by one or 2 drugs ( as many centers believe ) with no other “marginal ” criteria , it would be acceptable .
*any diabetic donor is to be excluded ( i”ll go with the OPTN ) in this one .
*GFR more the 80 .
*Age till 65 , as delayed graft function and decreased graft survival in older than 70 years donors is suspected .
*BMI to be decreased from 40 to 30 and from 35 to 30 before donation .
i believe Tailoring the Criteria according to different settings including the recipient is vital and improves the decision quality.
References:
Abramowicz D, Cochat P, Claas FH, Heemann U, Pascual J, Dudley C, et al. European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Nephrol Dial Transplant. 2015 Nov;30(11):1790–7.\
Englum BR, Schechter MA, Irish WD, Ravindra KV, Vikraman DS, Sanoff SL, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation. 2015 Feb;99(2):309–15.
Garg AX, McArthur E, Lentine KL; Donor Nephrectomy Outcomes Research (DONOR) Network. Gestational hypertension and preeclampsia in living kidney donors. N Engl J Med. 2015 Apr;372(15):1469–70.
Lentine KL, Segev DL. Understanding and communicating medical risks for living kidney donors: a matter of perspective. J Am Soc Nephrol. 2017;28:12–24.
Slinin Y, Brasure M, Eidman K, et al. Long-term outcomes of living kidney donation. Transplantation 2016;100:1371–1386.
Donor in the Child bearing period is better not to concept after donation due to possible risks of eclampsia and preeclampsia , and this should be individualized as well according to the comorbidities , obesity , etc.
If we are talking about life donors, it is better to wait for 3 months after donation. Usually, they wait longer. Pregnancy is not contraindicated. I defer the discussion till later. You will have extensive materials about living donation and pregnancy.
Morbid obesity (most commonly defined as body mass index (BMI) >35 kg/m2) is considered a relative contraindication for living kidney donation (1).
Pretransplantation loss of weight is recommended. Additionally, a healthy lifestyle (eg, exercise, healthy diet, tobacco abstinence) should be encouraged post-donation (1).
pre and post transplant weight control is advised and recommended by the OPTN , BMI more then 35 to 40 is considered as a relative contraindication and should be taken in context of other comorbidities and general well being
Ala Ali
Admin
3 years ago
Another question; Did you ever think of the term expanded criteria live donor!? Please write your thought about who could be an EC live donor? Why we are looking for such donors if ever?
As explained in the previous contributions, the expanded criteria donor (ECD) describes a donated kidney with suboptimal characteristics.ECD is increasing rapidly to expand the available donor pool by including more organs that were previously not accepted for donation (1).
When applying the same principles to the living donation process, we will face the ethical challenge of causing no harm to the donor. The donor with systemic or isolated kidney disease making it suboptimal is undoubtedly at risk of developing a variable degree of chronic kidney disease up to renal failure by himself.
Even in healthy donors, we should not forget that kidney donation carries a small but actual risk of developing kidney disease (2).
References:
1) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
2) Muzaale AD, Massie AB, Wang MC, et al. risk of end-stage renal disease following live kidney donation.JAMA. 2014 Feb;311(6):579-86.
My own understanding from my reading is that OPTN has defined some absolute contraindications for living kidney donation that includes diabetes mellitus and hypertension with evidence of end-organ damage (1).
I believe the rationale behind this is to avoid loss of the viable nephron mass (by unilateral nephrectomy) in a person who already suffers from subclinical loss of active nephrons. Furthermore, he is at risk of developing kidney disease in the future secondary to his underlying kidney disease. Here, the situation is different from retrieving the kidney from a deceased donor when we will only evaluate the benefit of this marginal kidney to the proposed recipient.
elderly donors, Diabetes, HTN, kidney stones & kidney cysts are considered marginal living donors
Because graft survival is better from living donor than deceased donors as living donors have limited ischemia time, better organ quality, and no inflammation (which occur after brain death)
graft survival from marginal living donors is similar to that of standard deceased donor but less than that of standard living donor
The potential harm to the donor is the ethical concern, presence of comorbidities, renal impairment after donor nephrectomy
System UR. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive; 2013.
Moore DR, Serur D, Rudow DL, Rodrigue JR, Hays R, Cooper M; American Society of Transplantation. Living Donor Kidney Transplantation: Improving Efficiencies in Live Kidney Donor Evaluation–Recommendations from a Consensus Conference. Clin J Am Soc Nephrol. 2015 Sep;10(9):1678–86
Englum BR, Schechter MA, Irish WD, Ravindra KV, Vikraman DS, Sanoff SL, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation. 2015 Feb;99(2):309–15.
Ala Ali
Admin
3 years ago
I have 2 questions for you;
Do you think that the OPTN-KDPI is applicable to your home unit?
If you are obliged to accept a donor with a high KDPI, how to select the best possible recipient? What is the main factor that could affect your decision and outcome?
Ala Ali
Admin
3 years ago
Dear all, Thanks a lot for your responses.
In your answers, please specify that the term ECD is for a Deceased Donation.
Define what is the difference between SCD and ECD, and how this affects the outcome.
Then justify your decision in accepting it or not.
Professor Ahmed Halawa
Admin
3 years ago
Dear All
Thank you for this interesting discussion, really enjoyable.
Will you accept a kidney from a diabetic deceased donor? If yes, what are your selection criteria?
This is a good and tricky question. It need knowledge about graft survival of DM donor, NonDM donor(DM donor with low KDPI, DM donor with high KDPI(>85%), non DM donor with low KDPI, Non DM donor with high KDPI)compared with waiting list for years.
great question to test the knowledge.
if I have a patient more than 40 years old on long waiting list without a suitable living donor, will consider to accept Diabetic deceased donor, provided low KDPI DM kidneys.
Here is why,
Jordana B cohen evaluated Survival benefit of transplantation with deceased diabetic donor kidney compared with remaining on the waitlist
– Study had median follow up of 8.9 years
– Patient who had received a diabetic donor kidneys Compared with patient who either remained on waiting list or received non diabetic donor kidney had decreased cumulative hazard of all cause mortality
– When KDPI taken into consideration – comparing with remaining in waiting list or transplantation with a non DM low KDPI kidneys, recipients DM of low KDPI kidneys and non DM high KDPI kidneys had significant lower HR of mortality
– Recipient of Diabetic high KDPI had no reduction in mortality
– age below 40 years at the time transplant had no reduction in mortality from accepting Diabetic donor kidney
Kidneys from donors with DM have frequently been refused for graft due to the possibility of presenting diabetic nephropathy, one of the main complications of this disease. However, with the increased need for organs for transplantation, the demand for kidneys from potential deceased donors has also increased, including diabetic deceased patients. A study of 2,300 kidneys from deceased diabetic donors (DDD) recipients concluded that the survival of these grafts was significantly lower (17%) when compared to non-diabetic donor grafts. It also concluded that there was no statistical difference in the mortality of these patients. A more recent work concluded that, after six months of transplantation, seven of nine patients with DDD grafts (77%) showed creatinine values from 1.3 to 2.4 mg/dl, meaning a good graft function.
For me, yes I would accept DDD, probably for the elderly and patients with multiple comorbidities.
References
1. Ahmad M, Cole EH, Cardella CJ, Cattran DC, Schiff J, Tinckam KJ, et al. Impact of deceased donor diabetes mellitus on kidney transplant outcomes: a propensity score-matched study. Transplantation. 2009; 88: 251-260.
2. Wolters HH, Brockmann JG, Diller R, Suwelack B, Krieglstein CF, Senninger N. Kidney transplantation using donors with history of diabetes and hypertension. Transplant Proc. 2006; 38: 664-665.
accepting diabetic deceased donor is associated with high mortality in recipient more than non diabetic deceased donor , but anyhow it is better than staying on dialysis. but this is not recommended if recipient is below 40 years of age.
i think pre transplant donor kidney biopsy should be done
1- How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria?
Please substantiate your answer
Expanded criteria donor (ECD, or marginal donor) refers to a kidney from a deceased donor aged 60 years or above, or aged 50-59 years with 2 additional risk factors that include: 1/ history of hypertension, 2/death as a result of CVA or 3/ elevated terminal serum creatinine. In December 2014, the kidney allocation system (KAS) intended to improve graft survival by allocating lower KDPI (kidney donor profile index) scores to lower EPTS (expected post-transplant survival) scores. Those with KDPI scores> 85% are similar to ECD. The risk of graft failure within 2 years after receiving ECD kidney was 70% higher than standard criteria kidney (SCK) transplants. Which means in other words while SCK transplant has an 88% 2 year graft survival, an ECD kidney transplant has an 80% graft survival. The recipient should be informed and consented that ECD kidney transplant doesn’t give superior graft survival outcome if compared to standard criteria donor. Usually it is accepted for older recipients to receive ECD kidneys from older patients. There are some benefits of ECD: 1- It can take care of around 12% of the waiting transplant list in ayear. 2- Having an ECD kidney carries a better quality of life and patient survival when compared to dialysis. 3- Future randomized controlled studies could help giving insight into how we could get better outcomes from ECD. Disadvantages of ECD compared TO standard criteria donation: 1- Less graft survival, more DGT, more rejection, more mortality. 2- Rapid return to renal transplant waiting list, so it gives false decrease of the number on the waiting list. Immunosuppression after ECD transplantation:
Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that ATG might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on m-TOR inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
Dear All
Thank you for this interesting discussion, really enjoyable.
Will you accept a kidney from a diabetic deceased donor? If yes, what are your selection criteria?
Hamdy Hegazy
3 years ago
1- How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria?
Please substantiate your answer
Expanded criteria donor (ECD, or marginal donor) refers to a kidney from a deceased donor aged 60 years or above, or aged 50-59 years with 2 additional risk factors that include: 1/ history of hypertension, 2/death as a result of CVA or 3/ elevated terminal serum creatinine. In December 2014, the kidney allocation system (KAS) intended to improve graft survival by allocating lower KDPI (kidney donor profile index) scores to lower EPTS (expected post-transplant survival) scores. Those with KDPI scores> 85% are similar to ECD. The risk of graft failure within 2 years after receiving ECD kidney was 70% higher than standard criteria kidney (SCK) transplants. Which means in other words while SCK transplant has an 88% 2 year graft survival, an ECD kidney transplant has an 80% graft survival. The recipient should be informed and consented that ECD kidney transplant doesn’t give superior graft survival outcome if compared to standard criteria donor. Usually it is accepted for older recipients to receive ECD kidneys from older patients. There are some benefits of ECD: 1- It can take care of around 12% of the waiting transplant list in ayear. 2- Having an ECD kidney carries a better quality of life and patient survival when compared to dialysis. 3- Future randomized controlled studies could help giving insight into how we could get better outcomes from ECD. Disadvantages of ECD compared TO standard criteria donation: 1- Less graft survival, more DGT, more rejection, more mortality. 2- Rapid return to renal transplant waiting list, so it gives false decrease of the number on the waiting list. Immunosuppression after ECD transplantation:
Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that ATG might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on m-TOR inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
ECD defined as deceased donor who is more than 60 years old or 50-59 years old in addition to 2 of the followings:
history of hypertension
death due to cerebrovascular accident
elevated terminal serum creatinine
Because of shortage in available kidneys of living donor or deceased SCD,
A trial to increase pool for donation by accepting “ECD” kidney which represent bad prognostic kidneys for wait-listed dialysis patients.
Subgroups with significant survival benefit after expanded criteria donor kidney transplantation according to epidemiological data
-Patients older than 40 yr
-Long median waiting time (> 4 yr)
-Patients with diabetes or hypertension
-Dialysis patients with vascular access problems
-Dialysis patients whose life expectancy in dialysis is lower than the estimated waiting time for kidney transplantation
The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Although most studies of ECD kidney transplantation confirm lower allograft survival rates, recipients of ECD kidneys generally have improved survival compared with matched dialysis-treated patients. Kidneys transplanted from ECDs have higher DGF rates, more acute rejection episodes and decreased long-term graft function. Despite these inferior results, these transplants have definitely survival advantage over dialysis patients remaining on transplant waiting list
-Merion RM, Ashby VB, Wolfe RA, Distant DA, Hulbert-Shearon TE, Metzger RA, Ojo AO, Port FK JAMA. 2005 Dec 7; 294(21):2726-33.
–Pascual J, Zamora J, Pirsch JD Am J Kidney Dis. 2008 Sep; 52(3):553-86. –Filiopoulos V, Boletis JN. World J Transplant. 2016;6:103–114.
fakhriya Alalawi
3 years ago
The widening gap between organ supply and demand is progressively increasing the waitlist time for patients seeking kidney transplantation. The increasing need for kidney grafts has led to a progressive expansion in the selection criteria for deceased and living donors (LDs). The terms- ‘Expanded-criteria donors’, ‘Marginal kidney donor’ is not yet clearly defined. It simply means the usage of suboptimal quality cadaveric renal grafts, non-heart-beating donors (NHBD), and living donors with some acceptable medical risks.
Simply, it can be identified as elderly patients or patients with comorbidities that were earlier considered to be unsuitable for donation. According to the US Renal Data System, the most frequent types of marginal LDs are those with older age, diabetes, hypertension, overweight and obesity, nephrolithiasis, malignancies, and kidney cysts. Not only those, but also kidneys that, though collected from standard donors, have complex arterial anomalies (e.g., more than 2 arteries though on a single patch or separated in such a way to need a double anastomosis or a bench reconstruction), kidneys with noticeable parenchymal damage (macroscopic sclerosis areas or sutured polar branches accidentally damaged during removal), and kidneys with complex anomalies of the excretory tract (complete double district), all conditions causing a loss functional mass.
Aging causes a series of morphological and physiological changes to the kidneys leading to an increased glomerular, vascular, and tubular senescence. Such morphological changes can result in significant functional changes including a decrease in renal blood flow and glomerular filtration rate, leading to an overall deterioration in renal function. The progressive loss of the renal mass and the decrease in the total number of functioning glomeruli cause a marked reduction of the functional reserve of the kidney, with the glomerulopenia being at the basis of a “remnant kidney” phenomenon causing progressive allograft failure. Moreover, kidney transplants from older donors are particularly susceptible to the negative impact of long cold ischemic time; a well-known independent risk factor for delayed graft function (DGF) associated with inferior graft survival.
Despite the survival benefits in recipients of marginal kidney transplants being inferior compared with those in recipients of standard criteria donor kidneys, yet, is significantly better than in those remaining on hemodialysis. Economic analysis suggests that transplantation with a marginal donor kidney is more cost-effective than dialysis treatment. Ojo et al. demonstrated that KT with a marginal kidney can increase the life expectancy by 5.1 years over maintenance dialysis treatment.
Older age does not represent a contraindication for living kidney donation. Collini et al. described a series of 38 patients undergoing KT (16 as single and 22 as double transplants) matched for age with donors aged 75 years or older (mean age 79.1 years, range 75–90 years). The 3-year actuarial graft survival rate was 64%, while the patient survival rate was 81.2%, with an acceptable renal function along the study period. Rather than actual age itself, kidney function, the presence of other comorbidities, and overall health should determine whether an older living kidney donor should be included or excluded. Importantly, impaired kidney function and health after donor nephrectomy may be more acceptable for older donors than younger ones because of shorter life expectancy. Similarly, a body mass index (BMI) >35 should not be considered as an absolute contraindication for living kidney donation.
Potential donors should be extensively evaluated and properly informed on the potential risks of donation, they should be aware that in some cases lifetime risks may be difficult to predict. Absolute and relative contraindications to living donation vary greatly across transplant centers worldwide and even nationally. Therefore, the choice to accept a potential donor often becomes subjective.
For me, whether I will be offering marginal donor to my CKD patients if present, yes I will do but for a certain group of patients, e.g., elderly to elderly after explaining all risk factors, patients with hepatitis C to hepatitis C-PCR positive.
References:
1. Cantarelli C, Cravedi P: Criteria for Living Donation from Marginal Donors: One, No One, and One Hundred Thousand. Nephron 2019;142:227-232.
2. Paride De Rosa, Giovanna Muscogiuri, Gerardo Sarno, “Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients”, International Scholarly Research Notices, vol. 2013, Article ID 301025, 8 pages, 2013. https://doi.org/10.5402/2013/301025
3. P. de Rosa, M. Santangelo, A. Ferrara et al., “Suboptimal kidney: the experience of a single transplant unit,” Transplantation Proceedings, vol. 36, no. 3, pp. 488–490, 2004.
Kidney transplantation is the best treatment of ESRD as it improves quality of life and survival compared to Dialysis , but due to increased patients exceeding the donors , so the need to expand the criteria of choosing the donor to reduce waiting list and the gap between the recipients and donors whatever deceased or living donors making them suboptimal donors not standard ..
The American United Network for Organ Shortage decided to accept donation from Extended Criteria Donors (ECD) which replaced the term of marginal kidney for the first time in 1997 by Kauffman , In 2002, a clear definition was given:
Extended criteria donors (ECD ) defined as: donors more than >60 years old or older or age 50-59 years and has at least 2 of three of the following:
*Cause of death is cerebrovascular
*terminal serum creatinine more than 1.5 mg/dl (132.6 µmol/L)
*history of hypertension.
Other definitions of marginal kidneys which have been studied by different authors as fibrosed kidneys based on histopathology, donation after cardiac death (DCD).
In 2019, in Europe, nearly 30% are ECD from potential donors 24% In North America, and nearly 40% of these kidneys are discarded each year .
Why marginal kidney is suboptimal donation
Kidneys from old donor ( aged kidneys ) are more susceptible to ischemia reperfusion injury (IRI).
Aging cells which are present in older kidney which resulting in a decreased tissue regeneration and chronic low level of inflammatory status , also Multiple mechanisms may explain the decreased tolerance to IRI as mitochondrial functions impairment results in reduction in antioxidant defenses, also heat shock protein 70 reduction which responsible for trans mitochondrial transport, and telomere shortening increases the process of aging .
Also hypertension may increase the level of aging cells in the kidney of the donor .
So we can say , the increased level of inflammatory status and edema caused by IRI in old kidneys can result in marked immune response .
Also dendritic cells functions as antigen presenting capacities are increased with age . Dendritic cells role in aging is still not fully understood , Moreover, it was shown that, after acute tubular necrosis (ATN) , the tubular cells showing marked expression of HLA molecules and inflammatory cells accumulation .
On the clinical aspect , delayed graft function which induced by IRI can result in 38% increased risk of acute rejection .
We can conclude That the effect of IRI on ECD kidneys is significant, and using machine of perfusion lowering the rate of delayed graft function and improved kidney survival rate as compared to cold storage .
-I will offer ECD to my CKD patients after explanation of risks ( delayed graft function , acute rejection , increased mortality in the first 200 days post transplant ….) and advantages that improving survival compared to Dialysis patients and written consent is mandatory .
Which patient I will select for ECD :
* older than 60 years.
*Patients with multiple access failure .
*Patients with life expectancy while on dialysis is lower than estimated waiting time for renal transplantation.
Reference:
Noble , J., Jouve , T., Malvezzi , P., et al .(2020). Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation.Frontiers in Immuunology , 10, 1-9.doi: 10.3389/fimmu.2019.03142
AHMED Aref
3 years ago
I want to add an option that can be used occasionally with ECD kidneys: Double kidney allocation.
The principle is to overcome the weakness of a single ECD kidney profile by offering the patient a chance of transplanting both kidneys en block (obviously, this is applicable only for programs allowing cadaveric transplantation).
The ECD should meet at least two of the following criteria for double kidney allocation to be considered:
– Age of donor more than 60 years.
– History of long-lasting diabetes.
– History of long-lasting Hypertension.
– Serum Cr more than 221 umol/L at time of retrieval.
– Low eGFR (less than 65 ml/min) at time of recovery.
– Glomerulosclerosis more than 15% and less than 50%.
To improve shortage in organ transplant donation , more criteria of acceptance is added in what is called expanded donor criteria ,which include using donors at the extremes of age, double kidney transplants from marginal donors, extended-criteria/Kidney Donor Profile Index (KDPI) >85 percent donors, and the use of living kidney donors (1). Expanded donor criteria is donor above 60years of age.
or a donor over the age of 50 with two of the following:
a history of high blood pressure, a creatinine greater than or equal to 1.5, or death resulting from a stroke.
We must get written permission from a patient before offering an ECD kidney. The decision to accept an ECD kidney is a personal decision. Accepting an ECD kidney may significantly decrease the amount of time a person waits for transplant.
Reference: 1-Jacobbi LM, McBride VA, Etheredge EE et al the risks, benefits, and costs of expanding donor criteria. A collaborative prospective three-year study. Transplantation. 1995;60(12):1491
Ibrahim Omar
3 years ago
marginal donors are borderline donors with less strict criteria. they include donors of older ages than 60 years and those with well-controlled ch. diseases.
I would offer it to CKD pts as it is still better than hemo or peritoneal dialysis.
selection criteria include old ages, pts with ch. viral infections, pts with well-controlled T2DM, HTN, …
Wael Hassan
3 years ago
Marginal donor is one of the deceased (cadaveric)donor
Their are standard one
Expanded one & marginal
In standard
Age<60
Cause of death no cerebrovascular event
Not diapetic
Last creatinine 60 but no other problems
Or between 50&60 and have any 2 of the following
Diapetic patient
HTN
Cerebrovascular event cause of death
Creatinine >1.5
Marginal criteria
Age>70 without any other problems
Or between 60&70 with
Diapetes
HTN
Proteinuria up to 1 gram
But gfr >50ml/min
Glumerulosclrosis<20% in renal biopsy more than 25 glomeruli
And surely it’s not preferred one
But it better than keep patient on HD (waiting list) as it offer more quality of live and survival
Fatima AlTaher
3 years ago
Marginal donor or expanded criteria donor refers to a less favorable deceased donor who previously would be rejected , but due to shortage in donor pool , these donors now can be used for special patients such as elderly and patients with short life expectancy.(1) Diagnostic chriteria of ECD 1- Age > 60 y without comorbidity 2- Age (50 -59) with 2 or more Hypertention Death from CVA Last premortem S Cr 1.5 mg/dl. 1- Maggiore, U., & Cravedi, P. (2014). The marginal kidney donor. Current opinion in organ transplantation, 19(4), 372-380.
Mahmoud Hamada
3 years ago
Marginal donor is the term used to describe kidneys from older donors, those with CVA, or other comorbidties such as type 2 dm, or hypertension. Also , those kidneys with impaired function as creat is 1.97 mg/dL.
The applicability of this option is based on patient to patient analysis. In other words, whether the recipient quality of life is a priority over long term graft survival as in older CKD patients. Also, for patient with HCV or HIV infections , whom may benefit from recipient with similar infections.
kidney donor profile index is donor scoring system involves 10 factors , determine donor quality and predict short and long term outcome, used in deceased kidney donor.
these factors age, race, HTN, DM, serum creatinine, HCV status, cause of death, donation after circulatory collapse, weight and height
Kidney Donor Profile Index is a parameter that has been developed to achieve an equal and effective distribution of deceased donor kidney to the get the best survival.
It is calculated using some donor date as age, weight. height and comorbidities. then a result form zero to 100 will be obtained . the lower the better chance of kidney survival.
Kidneys with lowest KDPI is first offered to pediatric waiting list then to adult with lower EPTS.
The Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney. These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death. lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function. example: KDPI of 20% will have a longer function than 80% of recovered kidney. on average, a kidney with KDPI<20% lasts 11,5 years a kidney with KDPI >20% TO <85 % lasts 9 years a kidney with KDPI > 85% lasts 5,5 years Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
The Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney. These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death. lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function. example: KDPI of 20% will have a longer function than 80% of recovered kidney. on average, a kidney with KDPI<20% lasts 11,5 years a kidney with KDPI >20% TO <85 % lasts 9 years a kidney with KDPI > 85% lasts 5,5 years Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
To know about KDPI, first we should know about KDRI (Kidney Donor Risk Index) score.
KDRI assesses relative risk of post-transplant graft failure and depends on:
1) Donor age
2) Race
3) Creatinine
4) Cause of death
5) history of diabetes
6) history of hypertension
7) height
8) weight
9) HCV status
10) NHBD (non heart beating donation)
KDPI is percentage of donors with KDRI score less than or equal to the donor’s KDRI score.
For example, if somebody has KDPT 85%, it means 85% of the donors have KDRI score less than the donor. The higher the KDPI, lower is the expected lifespan of the donated kidney.
Shereen Yousef
3 years ago
disparity between the availability of organs and waiting patients for transplants has forced many transplant centers across the world to use marginal kidneys from marginal donors. Marginal kidney donors can be defined as: all donors older than 60 years, donors older than 50 years with any of the following criteria: (1) hypertension, (2) cerebro-vascular cause of brain death or (3) pre-retrieval serum creatinine (SCr) level > 1.5 mg/dl, with a degree of glomerulosclerosis >15% and prolonged cold ischemia.
Transplantation with marginal cadaveric kidney donor is established. There is published evidence of its better outcome than waitlisted patients on dialysis regarding patient survival and quality of life.
Using a non-heart-beating donors is still in a plateau phase and comprises a minor percentage of deceased donations.
The main concern is primary non-function of the renal graft apart from legal and ethical issues.
There has been an increased use of marginal living kidney donors with some acceptable medical risks with a main concern is the safety of the living donor. There is not enough scientific data available to quantify the risks involved for such donation.
marginal donor can be either Complex living donor ,Non-Heart-beating donor (NHBD) or
Deceased or cadaveric donor
marginal deceased donor emphasizes on the graft being marginal and the only affects recipient outcomes. In the marginal living donor, focus is on the potential harm to the donor. Steiner[1] used the term ‘IMA donors’ for donors with isolated medical abnormalities. But multiple risk factors for future kidney disease may coincide in the same patient.
The term ‘Complex living donor’ used by Resse[2] is probably preferred for all suboptimal donors
The definition of “normal” GFR changes with age and it decreases over time The decrease in GFR is approximately 1 ml/min/1.73 m2 per year after age 40. There is an acute decrease in GFR of approximately 30% after unilateral nephrectomy; however, the impact of unilateral nephrectomy on this rate of decline in GFR is unknown. Acceptable GFR in a donor is that which can be predicted to provide adequate function for both donor and recipient after donor nephrectomy/transplantation. A GFR of ≥80ml/min is generally considered as accepted value although some centers use ≥60ml/min. GFR corrected to the age rather than age itself determines acceptability for donating.Age related physiological changes are also responsible of an increased risk of nephrotoxicity due to medications, including the commonly used immunosuppressive
medications as calcineurin inhibitors (CNIs) cyclosporine and tacrolimus [3].
using age matching of elderly donors and recipients is effective system for organs from elderly donors with good results .
For me i would recommend ECD for a selected number of patient:
•Older patient >55 years old.
•Patient with multiple failed vascular access.
•Patients with waiting time for transplantation more than 4 years.
•young patients with dialysis complications and low expected survival.
1-Steiner R. How should we ethically select living kidney donors when they all are at risk? Am J Transplant. 2005;5:1172–3.
2-Reese PP, Caplan AL, Kesselheim AS, Bloom RD. Creating a medical, ethical and legal framework for complex living kidney donors. Clin J Am Soc Nephrol. 2006;1:1148–53.
3-M. Naesens, D. R. J. Kuypers, and M. Sarwal, “Calcineurin inhibitor nephrotoxicity,” Clinical Journal of the American Society of Nephrology, vol. 4, no. 2, pp. 481–508, 2009.
Amit Sharma
3 years ago
Marginal donor/ Expanded criteria donor:
Due to a large demand-supply gap between kidney recipients and donors, OPTN (Organ Procurement and Transplantation Network) defined ECD (Extended Criteria Donor) as a brain dead donor aged more than or equal to 60 years OR between age 50 to 59 years with at least 2 out of the 3 conditions, namely, history of hypertension, a terminal serum creatinine of >1.5 mg/dl , or a cerebrovascular cause of death. (1)
The term ECD was originally coined in context of deceased donor program, the main aim being to reduce the rate of discarding kidneys as it has been shown that getting a transplant from ECD is better than remaining on dialysis. (1,2)
The term marginal donor is a better term, which will include: (3)
a) Marginal cadaveric kidney donor
b) Non Heart Beating donor (NHBD) or Donation after Circulatory Death (DCD)
c) Complex living donor
a) Marginal cadaveric kidney donor is the donor defined as ECD by the OPTN.
b) NHBD/ DCD is a donor who has sustained irreversible brain injury and has been declared dead after cardiac asystole. Such donors do not fit into the criteria of brain-dead donors. These kidneys have a prolonged warm ischemia time. Hence their results are suboptimal.
c) Complex living donor is a living donor who does not fit in the standard living donor guidelines. Such a donor may include medical risk factors like age more than 65 years, family history of ESRD in first degree relation, family history of Diabetes in a first degree relative, impaired fasting glucose, hypertension, dyslipidemia, obesity, hematuria, proteinuria, renal stones, borderline normal GFR etc. (4,5)
Would you offer it to your CKD patients?
Yes. Data has shown that getting a marginal donor transplant is better than remaining on a wait-list. (1,2)
Although this would be an informed choice by the prospective recipient
References:
1) Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005;294:2726-2733.
2) Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol 2001;12:589-597.
3) Gopalakrishnan G, Gourabathini SP. Marginal Kidney Donor. Indian J Urol 2007;6-293.
4) Reese PP, Caplan AL, Kesselheim AS, et al. Creating a medical, ethical and legal framework for complex living kidney donors. Clin J Am Soc Nephrol 2006;1:1148-53
5) Umberto M, Paolo C. The marginal kidney donor. Curr Opin Organ Transplant 2014;19:372-380
Weam Elnazer
3 years ago
ECD kidneys are those either from
1-a deceased donor ≥ 60 years of age,
2-or a donor 50 to 59 years of age with at least two of the following features:
history of hypertension, terminal serum creatinine > 1.5 mg/dL (133 mmol/L), or cerebrovascular cause of death
3-non heart-beating donors.
4-HCV donor
now KDPI replaced (SCD AND ECD) and based on :
age, height, weight, ethnicity,h\o of Hypertension or DM, causes of death, terminal creatinine, Hep (C) status and donated a kidney after circulatory death.
a kidney with a KDPI OF < 20% based on calculated factors should survive longer than 80% of the previous years harvested kidney.
on average, a kidney with KDPI<20% for the last 11,5 years
a kidney with KDPI >20% TO <85 % LAST 9 YEARS
a kidney with KDPI > 85% LAST 5,5 YEARS
upon that, patients who previously would only accept an SCD kidney would default to accepting a kidney with a KDPI OF <85%
Expanded criteria donors for kidney transplantation. Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Am J Transplant. 2003;3:114–125
United Network of organ sharing.
Mohamad Habli
3 years ago
How would you define marginal donor (expanded criteria donor)?
The expanded criteria donor (ECD) is any donor over the age of 60, or a donor over the age of 50 with two or more of the following: hypertension, creatinine greater than or equal to 1.5, or death resulting from a CVA. Kidney donation from deceased donor due to CVA is considered in the ECD because the majority of CVA are ischemic in origin resulting from rupture of atherosclerotic plaque which indicates vascular disease, renal vessels in this case are not exception. Hemorrhagic CVD could also result from hypertensive emergencies in which renal vessels are also implicated.
Large retrospective studies have showed higher rate of delayed graft function, episodes of acute rejection in the first year and lower graft survival of ECD comparing with SCD. However,when comparing ECD with waitlisted patients on dialysis, there was improvement in life expectancy. Would you offer it to your CKD patients? If yes, what would be your selection criteria?For my patient, marginal kidney could be offered if patient satisfies following criteria.
The selection criteria for EDC would be with Older patients, although recent Belgian cohort suggested that older patients might gain a survival benefit with SCD versus dialysis, but any survival benefit with ECD transplantation may be small, comorbid patients who are hypertensive and or diabetic patients, patients with vascular access problems, patients with low immunological risk patients, long median waiting list> 4 years ,KPDI 85 or higher % beside, dialysis patients whose life expectancy on dialysis is lower than the estimated time for renal transplantation.
The transplant center must get written permission from a patient before offering an ECD kidney. The decision to accept an ECD kidney is a personal decision. Accepting an ECD kidney may significantly decrease the amount of time a person waits for transplant.
Asmaa Khudhur
3 years ago
Expanded Criteria Donor (They are also referred to as donors with “medical complexities”.ECD donors are normally aged 60 years or older, or over 50 years with at least two of the following conditions hypertension history, serum cr.>1.5 mg/dl or cause of death from cerebrovascular accident.
The use of organs from “marginal” or expanded criteria donors (ECD) has increased the pool of kidneys available for kidney transplantation.Recipients of these kidneys have a relative risk of graft loss greater than 1.70 compared with kidneys from a reference group of donors aged 10–39 years without any of the other three conditions. Recipients of ECD kidneys experience a survival benefit from transplantation when compared with candidates who remain on the waiting list .
study of Rochel suggest that older patients might gain a survival benefit with SCD transplantation versus dialysis, but any survival benefit with ECD transplantation versus dialysis may be small.
Reference
Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort
Rachel Hellemans, Anneke Kramer, Johan De Meester, Frederic Collart, Dirk Kuypers, Michel Jadoul, Steven Van Laecke, Alain Le Moine, Jean-Marie Krzesinski, Karl Martin Wissing … Show more
Nephrology Dialysis Transplantation, Volume 36, Issue 5, May 2021, Pages 918–926, https://doi.org/10.1093/ndt/gfab024
Assafi Mohammed
3 years ago
ECD is defined as :
any donor above the age of 60. Or
donor above the age of 50 with one of the following :a history of hypertension, a serum creatinine level greater than or equal to 1.5 mg/dl or death resulting from cerbro-vascular events.
I would offer my patient ECD kidney after informed consent. I would let him know that having ECD kidney might be associated with a higher possibility of temporary dialysis or graft loss, but in the other side ECD kidney found to be associated with superior survival when compared to keeping on dialysis, adding to that ECD kidney may shorten the time a recipient waits for transplant.
My Selection Criteria Will Be:
Patients knwon to have low immunological risk.
Dialysis patients with DM, vascular access problems and other comorbidities, provided that his life expectancy while being on dialysis is more than 1year .
Diaysis patients whose life expectancy while on dialysis is shorter, compared to time waiting for transplant.
Types of marginal donor (ECD) 1.Complex living donor Type of risk factor & Example
• Evidence of current renal disease
eg:Hematuria, proteinuria, nephrolithiasis
• Direct risk for CKD
eg:Hypertension, obesity
• Reduced nephron mass
Age ≥65 years
• Genetic risk factor
Family h/o of ESRD in 1st relative
• Risk factor for a CKD
Diabetes in a first-degree relative, Impaired fasting glucose
• Cardiovascular risk factor
Smoking, hyperlipidemia, hypertension
• Other
Black race, sickle trait
• Combination of previous risk factors
Hypertensive black patient
2.Non-Heart-beating donor (NHBD)
The NHBD is a donor who has suffered an irreversible brain injury.
Many transplant centers are reluctant to use kidneys from NHBDs due to relatively higher incidence of primary nonfunction (PNF). Issues like uncertainty regarding diagnosis of death on the basis of cessation of cardiac activity (cardiac death), logistics of family consent involved in the procurement of organs and prolonged warm ischemia all contribute to its slow development. It is important to educate the public, hospitals and physicians about the possibilities of organ donation from NHBDs. Public trust is most important in the success of any transplant program.
3.Deceased or cadaveric donor
In a consensus statement, an international panel of pathologists presented a methodology to assess the marginal kidneys based on the viable nephrons to guide about single or dual transplantation or discard the organ.This panel suggested a biopsy-based scoring system for kidneys, with scores ranging from a minimum of 0 (indicating the absence of renal lesions) to a maximum of 12 (indicating the presence of marked changes in the renal paren-chyma). Kidneys with a score of 3 or lower were predicted to contain enough viable nephrons for single transplants. Those with a score of 4, 5 or 6 could be used as dual trans-plants, on the assumption that the sum of the viable nephrons in the two kidneys approached the number in one ideal kidney. Kidneys with a score of 7 or greater were discarded, since it was assumed that they would not deliver sufficient number of nephrons, for even dual transplanta-tion.
(*) Remuzzi G, Grinyo J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol. 1999;10:2591–8. [PubMed] [Google Scholar]
Pirani CL, Salinas-Madrigal L. Evalua-tion of percutaneous renal biopsy. In: Sommers SC, editor. Kidney pathology de-cennial, 1966–1975. New York: Appleton-Century-Crofts; 1975. [Google Scholar]
Last edited 3 years ago by Assafi Mohammed
Wessam Moustafa
3 years ago
The very long transplant waiting lists has led to the use of expanded criteria donor kidneys in an effort to increase the donor pool
ECD referes to donors with suboptimal criteria
Expanded criteria donor is a donor characterised by :
1) age above 60
2) age from 50-59 with 2 of the following:
*hypertensive
*creatinine 1.5 or higher
* brain death from cerebrovascular event
Marginal donors aalso include diabetic patients , the non-heart-beating cadaver donors, or those with anatomical abnormalities
Incidence of graft loss is higher with expanded criteria donors , some physicians may proceed to dual kidney transplant to overcome this probleme
Expanded criteria donor greatly shortens waiting time on transplant lists , and survival of patients transplanted using ECD is better than staying on dialysis
Patient should be informed and consenting before being transplanted using ECD kidneys .
It may be very beneficial to recipients with expected short life spans
F. K. Port, J. L. Bragg-Gresham, R. A. Metzger et al., “Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors,” Transplantation, vol. 74, no. 9, pp. 1281–1286, 2002.View at: Google Scholar
R. M. Merion, V. B. Ashby, R. A. Wolfe et al., “Deceased-donor characteristics and the survival benefit of kidney transplantation,” Journal of the American Medical Association, vol. 294, no. 21, pp. 2726–2733, 2005.
A. O. Ojo, J. A. Hanson, H.-U. Meier-Kriesche et al., “Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates,” Journal of the American Society of Nephrology, vol. 12, no. 3, pp. 589–597, 2001.
Expanded criteria donor is defined as;
A-Kidney donors over the age of 60 years without co morbidities .
B-Kidney donors age between 50-60 years with two co morbidities or more of the following ;
1-hypertension
2-Death from cerbrovascular accident .
3-Serum creatinine level more than 1.5 mg/dl
Selection criteria ;
1-For the donor, the Kidney Donor profile Index would be used to profile the donor kidney
2-For the recipient an older recipient would be selected to receive the ECD kidney.
3- Donor and recipient age matching is ethically fair and physiologically logic “old-for-old” program l.
4- Deceased donors aged65 years and older are allocated to un sensitized recipients aged 65 years and older .
5- Donor HLA-typing is not required, so allocation is done by using only ABO group matching, negative cross match, and a local allocation based on waiting time in order to keep cold ischemia time to a minimum.
KDPI;
A numerical measure estimated by calculating kidney donor risk index (KDRI) for a deceased donor
KDRI;
An estimation of relative risk of kidney graft failure from deceased donor compared to reference donor
KDPI used for
matching candidates with longer estimated post transplant longevity (EPTS) of 20% or less with kidneys from donor with KDPI of 20% “longevity matching”
yes, preferred to be in elderly recipient as they have better patient survival after kidney transplant than those waitlisted on dialysis (1)
Reference ;
1- Wang Ziting et al. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian Journal of Urology.Vol 36. Issue 2 2020
2-F. K. Port, J. L. Bragg-Gresham, R. A. Metzger et al., “Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors,” Transplan-
tation, vol. 74, no. 9, pp. 1281–1286, 2002.
3- L. Fritsche, J. H ̈orstrup, K. Budde et al., “Old-for-old kidney allocation allows successful expansion of the donor and recipi- ent pool,” American Journal of Transplantation, vol. 3, no. 11, pp. 1434–1439, 2003.
4- W. H. Lim, S. Chang, S. Chadban et al., “Donor-recipient age matching improves years of graft function in deceased-donor kidney transplantation,” Nephrology Dialysis Transplantation, vol. 25, no. 9, pp. 3082–3089, 2010.
5-(1) Rose, C., Gill, J., & Gill, J. S. (2017). Association of kidney transplantation with survival in patients with long dialysis exposure. Clinical Journal of the American Society of Nephrology, 12(12), 2024-2031.
The expanded criteria donor (ECD) is
ü any donor over the age of 60,
ü or a donor over the age of 50 with two of the following:
o a history of high blood pressure,
o a creatinine (blood test that shows kidney function) greater than or equal to 1.5,
o or death resulting from a stroke.
Selection criteria : patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy
Extended criteria donors
the use of ECD is increasing rapidly as a means of expanding the available donor pool
previously not considered for transplantation , they now represent about 25 % of donors
criteria :
age more than 60
age 50-59 and two or more of ( HTN, sCr more than 1.5 mg/dl , cerebrovascular cause of death)
super extended criteria donors : age more than 70
It has at least a 70% increased risk for failure within 2 years compared with standard criteria kidneys
they are offered only to those patients who have agreed to accept them , who have been informed of the risk
Expanded criteria donor:
How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria?
Please substantiate your answer
Source of donor kidney
LD, related or unrelated
DD, comparing old recipient with young one older recipient has less chance to receive a living donor kidney.
Living donor once available associated with better graft and patient survival, also allow for preemptive KTX which again associated with superior outcome.
Old recipient likely will get older donor age above 60 with shorter graft survival as compared to young donors .
Waiting list for donation increased to 14% waiting for more than 5 years in 2019and 40% of DD recipient waiting on dialysis more than 5 years . Those with blood group O, B, sensitized patient even waits longer
Allocation DD program depend on the following:
EDC, expanded donor criteria, recipient characteristics, waiting list time
EDC expanded donor criteria::
Donor age above 60, or between 50-59 years with any of two
1-Creatinine > 1.5mg /dl,
2- cerebrovascular accident cause of death, or
3)-hypertension.
It has been anticipated that at 3 years, 70% of ECD kidneys with serum creatinine greater than 1.5 would be lost (1).
Systematic review of the literature from case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs conclude patients younger than 40 years or scheduled for retransplantaion should avoid the ECD kidney due to the poor graft survival while . Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long-expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy(2).
i would apply the EDC in selected type of recpients whom older than 50 , limited vascular access with long waiting dailysis time
1-Selective use of expanded criteria donors for renal transplantation with good results
S M Greenstein 1, G Schwartz, R Schechner, J Pullman, C Jackness, V Tellis, Transplant Proc
. 2006 Dec;38(10):3390-2.
2-A systematic review of kidney transplantation from expanded criteria donors
Julio Pascual 1, Javier Zamora, John D Pirsch, Am J Kidney Dis. 2008 Sep;52(3):553-86.
Expanded Criteria donors:
This definition was introduced by the Organ Procrurement and Transplantation Network (OPTN) in the year 2002. This definition does not include Donor after cardiac death
Yes I would offer it to CKD patients after careful selection based on the available epidemiological data as follows
Pros of ECD
the annual mortality rate in Hemodialysis patients is more than 20%
the rapidly growing transplant waitlist and subsequently increasing longer waiting time on HD, worsens overall patient survival
There has been definite survival advantage of ECD kidney transplant recipients over dialysis patients on waitlist in terms of overall mortality benefit
Cons of ECD
It has been documented that 70% risk of graft failure versus standard criteria donor
17% primary graft non function is reported as compared to SCD
38% of all the ECD kidneys were discarded versus 9% of all kidneys due to small kidneys
IT has been shown to have increased treatment cost and resource use due to increased hospitalization
The mortality in the peri operative period is higher in ECD kidney transplant recipients as compared to SCD recipients. This is due to increased episodes of acute rejection needed more hospital admissions and dialysis
There are definite subgroups which show significant survival advantage after ECD
The survival advantage of ECD kidneys were more to older kidney recipients than younger ones probably due to shorter life expectancy in older recipients.
References:
EXPANDED CITERIA DONOR (ECD)IS THE DONOR MORE THAN 0 YEARS OLD OR BETWEEN 50 TO 59 YEARS OLD AND HAVING 2 OF THE FOLLOWING:
1- DEATH RELATED TO CEREBROVASULAR ACCIDENT
2-HISTORY OF SYSTEMIC HYPERTENSION
3-TERMINAL SERUM CREATININE MORE THAN 1.5 MG/DL
ECD IS ASSOCIATED WITH 70% FAILURE COMPARED TO USING STANARD CRITERIA DONOR.ECD HAS BETTER SURVIVAL IN COMPARISON TO DIALYSIS PATIENTS.WITH STRATIFICATION OF DONOR AND RECIPIENT RISK,ALLOGRAFTS FROM ECD HAVE EXCELLENT SHORT TERM OUTCOMES.THIS APPROACH ACSHIEVED MAXIMAL UTILIZATION ,DECREASING KIDNEY DISCARD AND DEATH DURING WAITING .IN ADDITION,IT IMPROVED REHABILITATION ANDQUALITY OF LIFE WITH CONSIDERATION OF PERSONAL AUTONOMY.
DOCUMENTED INFORMED CONSENT MUST BE THERE WITH USING ECD ALLOGRAFT,INCLUDING THE RISK,CLEAR AWARENESS OF FAILURE POSSIBILITY WITH INFORMED PERCENTAGE.
REFERENCES:
B.RAMIREZ,CG & McCAULTY,J:CONTEMPORARY KIDNEY TRANSPLANTATION,SPRINGER:2018:76
DANOVITCH,GM: HANDBOOK OF KIDNEY TRANSPLANTATION sixth edition;94
Expanded Criteria Donor [ECD] is defined as
patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy
https://www.sciencedirect.com/journal/american-journal-of-kidney-diseases
Expanded Criteria Donor [ECD] is defined as
4 donor variables are used as criteria for being categorized as ECD: age of donor, serum creatinine value, cause of death and a history of hypertension
Yes i would offer an Expanded criteria donor kidney to my patients. Studies have shown that even though these kidneys are associated with some risk of earlier graft loss, they still function well: it is estimated that 8 out of 10 ECD kidneys would still be functioning at 1 year while 9 out of 10 Standard Criteria kidneys will be funtioning at 1 year. Renal transplant offers better quality of life and higher survival rates than remaining on dialysis or on the transplant wait list, so an ECD kidney transplant will do the patient better than waiting in the queue/ on dialys for a SCDonor.
Selection Criteria
Wang Ziting et al. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian Journal of Urology.Vol 36. Issue 2 2020
Noble J et al. Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation. Front Immunol. 2020
Selection Criteria:
The recipient with an EPTS score of </=20% gets a kidney with a low KDPI.
A Guide to Calculating and Interpreting the Estimated Post-Transplant Survival (EPTS) Score Used in the Kidney Allocation System (KAS) Updated: April 21, 2020. Organ Procuement and Transplantation Network
The expanded criteria donors describes the suboptimal quality grafts from deceased donors including grafts from donors above 60 years old and donors or donors above 50 years with 2 of the followings: history of HTN, cerebrovascular cause of death, pre retrieval creatinine above 1.5 mg/dl.
Marginal donors is more broad term include deceased donors above 70 years with no risk factors or donors between 60-70 years with history of HTN, DM, proteinuria.
The use of expanded criteria or marginal donors is associated with relative risk of graft loss, however can be used in special situation to decrease the waiting list.
These type of grafts could be used in older patients with decreased expectancy of long life.
Ref:
Selective use of expanded criteria donors for renal transplantation with good results – PubMed (nih.gov)
The expanded criteria donor (ECD) is an effort to increase the donor pool. ECD kidneys are used to expand the number of deceased-donor kidney transplants, particularly for elderly recipients.it has two criteria
1. donor over the age of 60.
2 donor over the age of 50 with two of the following: a history of high blood pressure, a creatinine (blood test that shows kidney function) greater than or equal to 1..5, or death resulting from a stroke..
I would offer ECD to some groups of ckd patient specially old age .
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4801786/#!po=14.7321
With increasing need to extend donor pool, OPTN defined marginal kidneys and then ECD in 2002. Deceased donors with age equal or more than sixty years old and donor between 50 -59 with more at least two of following condition were considered as ECD: patients with previous history of HTN, serum creatinine equal or more than 1.5 mg/dl, CVA as cause of death. Although outcome of standard citeria transplantation is better than ECD transplantation but is still better than dialysis patients. So this would be a good option in selected conditions. Quality of these grafts can be assessed using kidney biopsy parameters before transplantation.
We consider ECD donors for the following candidates in our center (Labafinezhad Hospital):
1- Recipients of the same age.
2- Recipients older than 40 years with diabetes.
3- Recipients older than 40 years are candidates for standard criteria transplantation.
We don’t use DCD donors in our center.
References:
1. Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-125.
2. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA. 2005;294(21):2726-2733
3.Pascual, J., Zamora, J., & Pirsch, J. D. (2008). A Systematic Review of Kidney Transplantation From Expanded Criteria Donors. American Journal of Kidney Diseases, 52(3).
4. Dedinská I, Palkoci B, Vojtko M, Osinová D, Lajčiaková M. Experiences With Expanded Criteria Donors: 10-Year Analysis of the Martin, Slovakia Transplant Center. Exp Clin Transplant. 2019 Feb;17(1):6-10.
The expanded criteria donor (ECD) is any donor over the age of 60, or a donor over the age of 50 with two of the following:
1- a history of high blood pressure.
2- a creatinine greater than or equal to 1.5 mg/dl.
3- death resulting from stroke.
The survival benefits seen in recipients of marginal kidney transplants are inferior compared with those in recipients of standard criteria donor kidneys, but significantly better than in those remaining on hemodialysis
Although advanced age is not recognized as a contraindication to kidney transplantation, KT in the elderly remains challenging and a careful selection of candidates, taking into account all the comorbidities being mandatory.
KDPI is a percentage score that provides how long the kidney is likely to function when compared to other kidneys.
KDPI depends on :
Age.
Height and weight.
History of hypertension.
History of diabetes.
Cause of death.
Serum creatinine.
HCV status.
Donor meets DCD criteria.
A KDPI score of 20% means that the kidney is likely to function longer than 80% of other available kidneys. A KDPI score of 60% means that the kidney is likely to function longer than 40% of other available kidneys .
EPTS depends on :
Age.
Current diabetes status.
Numbers of previous transplants
Receiving chronic dialysis.
The EPTS score estimates how long the candidate will need a functioning kidney transplant when compared with other candidates. A person with an EPTS score of 20% is likely to need a kidney longerlive longer than 80% of other candidates. Someone with an EPTS score of 60% will likely need a kidney longer than 40% of other peoples.
KDPI scores ≥ 85% are similar to the previously designated “ECD” kidneys and like “ECD” kidneys, are deemed to be viable for transplant in the appropriate recipients , typically older patients, those who cannot withstand dialysis for an extended period of time, and those recipients with high EPTS score. Additionally, KDPI ≥ 85% are made available to a wider geographic region than all other kidneys in an attempt to locate a suitable candidate in the quickest manner possible. Modeling of the KAS predicted that the tandem use of KDPI and EPTS would produce a significant rise in the “average projected median lifespan after transplantation,” as well as the “time with a functional allograft.
References:
Gebel H, Kasiske B, Gustafson S, et al. Allocating deceased donor kidneys to candidates with high panel reactive antibodies. Clin J Am
Soc Nephrol 2016;11:505–511.
Hall E, Massie A, Wang J, et al. Effect of eliminating priority points for HLA-B matching on racial disparities in kidney transplant rates.
Am J Kidney Dis 2011;58:813–816.
Leichtman A. Improving the allocation system for deceased-donor kidneys. N Engl J Med 2011;364:1287–1289. 77.
☆ Marginal donor (expanded criteria donor) is any donor who
• > 60 years or
• 50-59 years with two other risk factors
. history of hypertension,
. death due to cerebrovascular event
. raised serum creatinine at retrieval > 1.5
mg/dl
* Danovitch
☆ Marginal kidney may be obtained from
• Marginal donors (as above)
• standard donors but with
. complex anomalies of blood supply (2 or
more arteries which may need to double
anastomosis).
. complex anomalies of the excreted pathway
(separated 2 ureters).
. observable parynchemal disease (as area of
macroscopic sclerosis).
* Paride De Rosa, Giovanna Muscogiuri, Gerardo Sarno, “Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients”, International Scholarly Research Notices, vol. 2013, Article ID 301025, 8 pages, 2013. https://doi.org/10.5402/2013/301025
———————–
Kidney Allocation System (KAS) was created in 2014 and has great achievements in shortening of waiting list of patients on dialysis and giving priority of transplantation of highly sensitized patients.
☆ Selection criteria is based on
• Donor —–> Kidney Donor Profile Index (KDPI).
• Recipient —–> Expected Post Transplant Survival (EPTS)
score
☆ KDPI gives idea about quality of donor kidney by using ten factors in donor to estimate the risk of graft failure after kidney transplantation (age, height, weight, ethnicity/race, history of hypertension, history of diabetes, serum creatinine:(mg/dL), HCV Status, donor meets DCD criteria?)
Range: 0 -100
Lower KDPI means longer graft survival
☆ EPTS is estimation of longevity of the graft by using four factors in recipient (age, time on dialysis, past history of any solid organ transplantation, diabetes status).
Range: 0 -100
Lower EPTS means longer years of graft function.
The kidneys with low KDPI values (20% or less) will be offered to candidates with the high score of EPTS (top 20 %)
* Israni, Ajay K., et al. “New National Allocation Policy for Deceased Donor Kidneys in the United States and Possible Effect on Patient Outcomes.” Journal of the American Society of Nephrology (2014): ASN-2013070784.
Dear All
I acknowledge your contribution
●●●Marginal cadaveric kidney donors can be
defined as: all donors older than 60 years, donors older than 50 years with any of the following criteria:
1- Hypertension.
2- cerebro-vascular cause of brain death.
3- pre-retrieval serum creatinine (SCr) level > 1.5 mg/dl, with a degree of glomerulosclerosis >15% and prolonged cold ischemia.
●● YES, i will offer it to my patients.
There is enough published evidence of its better outcome than waitlisted patients.
The focus is on finding various ways to improve the outcome of such marginal grafts.
In a consensus statement, an international panel of pathologists presented a methodology to assess the marginal kidneys based on the viable nephrons to guide about single or dual transplantation or discard the organ.
●● SELECTION CRITERIA according to this panel :
This panel suggested a biopsy based scoring system for kidneys, with scores ranging from a minimum of :
0 (indicating the absence of renal lesions) to a
maximum of 12 (indicating the presence of marked changes in the renal parenchyma).
●● Kidneys with a score of 3 or lower were
predicted to contain enough viable nephrons for single transplants.
Those with a score of 4, 5 or 6 could be used as dual transplants, on the assumption that the sum of the viable nephrons in the two kidneys approached the number in one ideal kidney.
Kidneys with a score of 7 or greater were discarded, since it was assumed that they would not deliver sufficient number of nephrons, even for even dual transplantation.
●● REFERENCES
1- 48. Remuzzi G, Grinyo J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol. 1999;10:2591–8. [PubMed] [Google Scholar] [Ref list].
2- 51. Pirani CL, Salinas-Madrigal L. Evalua-tion of percutaneous renal biopsy. In: Sommers SC, editor. Kidney pathology de-cennial, 1966–1975. New York: Appleton-Century-Crofts; 1975. [Google Scholar] [Ref list]
3- 52. Pirani CL. Evaluation of kidney biopsy specimens. In: Tisher CC, Brenner BM, editors. Renal pathology, with clinical and functional correlations. Philadelphia: JB Lippincott; 1994. pp. 85–115. [Google Scholar] [Ref list]
Marginal donor or expanded criteria donor
refers to a less favorable deceased donor who previously would be rejected , but due to shortage in donor pool , these donors now can be used for special patients such as elderly and patients with short life expectancy.(1)
Diagnostic chriteria of ECD
1- Age > 60 y without comorbidity
2- Age (50 -59) with 2 or more
Hypertention
Death from CVA
Last premortem S Cr 1.5 mg/dl.
1- Maggiore, U., & Cravedi, P. (2014). The marginal kidney donor. Current opinion in organ transplantation, 19(4), 372-380.
Marginal kidney or expanded criteria donor (ECD) means that when the donor is above 60 years old or above 50 with history of hypertension or his serum creatinine greater than or equal to 1.5 mg/dl or when the donor died due to cerebrovascular cause.
ECD helps the patient to decrease waiting time till transplant but the recipient should be informed and should have his permission because it has a risk of earlier graft loss than the ideal kidney or standar criteria of donor but the exact risk is unknown.
ECD still remains superior or better than keeping the patient on dialysis but it depends on recipient age and survival advantages or disadvantages from the transplantation.
Absence of living donor make ECD is good choice especially for those patients who are old age on dialysis, also it’s used in diabetic and /or hypertensive patients .
In summary ECD is useful for old age group patients on waiting list and old age patients with HTN and / or DM with poor survival rate but they achieve great benefits after ECD transplant compared to those patients remaining on dialysis.
Many studies showed that kidneys from ECD are more immunogenic and that affect graft survival and increase incidence of rejection which depend mainly on recipient age and type of immunosuppressive regimen.
Most recipient from ECD are old age so it’s important to focus on induction and maintenance of immunosuppressive medications and to take care of high risk of infection and other side effects.
Expanded criteria donor or marginal kidney is a term to describe the quality of deceased donor kidneys it include:
Donor older than 60 years or aged 50 to 59 with two additional risk factors:
History of hypertension
Death as a-result of cerebrovascular accident
Elevated serum creatinine more than 1.5mg/dl
It offered for patients who had agreed to accept them and informed about the risk of failing is 70% in the next 2 years
The selection criteria would be for the desperate patients who waited for long time and had complications in dialysis
Due to the increased demand in transplantable organs, the gap between kidney graft and supply grows. The organ shortage continues despite the fact that surgeons have liberalized their acceptance criteria for suitable deceased donor organs, have exploited the use of ABO-incompatible and marginal ‘expanded criteria donors (ECD)’. However, kidneys from ECD donors come with their relative risk of graft failure of 1.7 compared with a reference group so it is offered only to those who accept that these kidneys are more likely to fail. Therefore, selection of kidneys from ECD donors remains extremely important to guarantee an adequate kidney function and graft survival for long-term. Some ECD donor kidneys are not accepted by many centers due to their extreme age and additional risk factors such as hypertension, diabetes mellitus of the donor. A comprehensive assessment of the ECD kidney is mandatory and long-term graft survival and kidney function need to be assure.
Expanded criteria donors ( ECD) defined as deceased donor who is more than 60 years old or 50-59 years old in addition to 2 of the followings:
.
The quality of the available kidney for transplantation can be estimated through calculating the kidney donor profile index ( KDPI).
factors used to estimate KDPI are:
The lower KDPI score associated with longer graft function.
So if the patient do not has a live donor and he accepted to receive an expanded donor criteria and the available organ is of a lower KDPI score and the recipient is of low expected post transplant survival, an ECD can be used for him.:
file:///C:/Users/hp/AppData/Local/Temp/msohtmlclip1/01/clip_image001.jpg
Older kidneys can be used in older recipients, the so-called “old-for-old” program. This form of age matching is ethically fair. According to this the Eurotransplant Senior Program (ESP), a well-established old-for-old allocation program existed since 1999 ,where deceased donors aged 65 years and older are allocated to unsensitized recipients aged 65 years and older, so HLA-typing is not required, allocation is done by using only ABO matching, negative crossmatch,and a local allocation based on waiting time in order to minimize cold ischemia time .
the Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney.
These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death.
lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function.
example: KDPI of 20% will have a longer function than 80% of recovered kidney.
on average, a kidney with KDPI<20% lasts 11,5 years
a kidney with KDPI >20% TO <85 % lasts 9 years
a kidney with KDPI > 85% lasts 5,5 years
Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
Thank you, Ahmed
The whole transplant community and not Surgeons only liberalized their acceptance criteria for suitable deceased donor organs.
You raised an important issue of (Old for Old) transplantation.
expanded criteria donorECD kidneys are those either from a brain-dead donor ≥ 60 years of age, or a donor 50 to 59 years of age with at least two of the following features: History of hypertension, terminal serum creatinine > 1.5 mg/dL (133 mmol/L), or cerebrovascular cause of death. These criteria for the definition of ECD were based on the presence of variables that increased the risk for graft failure by 70% (relative hazard ratio 1.70) compared with a standard criteria donor (SCD) kidney. Kidney transplants coming from donation after cardiac death (DCD) are not included in this definition. SCD was defined as a donor who does not meet the criteria for DCD or ECD
The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool.
Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies.
**Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression? Vassilis Filiopoulos, John N Boletis,World J Transplant. 2016 Mar 24; 6(1): 103–114.
for me, I don’t prefer ECD to my CKD patient unless dialysis has life-threatening complications/contraindications or if the patient accepts the risks of transplantation of ECD especially high immunosuppressive medications after full explanation
The term marginal criteria donor replaced the term expanded criteria donor (ECD)
which describe kidney from deceased donor
KDPI
KDRI
KDPI used for
yes, preferred to be in elderly recipient as they have better patient survival after kidney transplant than those waitlisted on dialysis (1)
(1) Rose, C., Gill, J., & Gill, J. S. (2017). Association of kidney transplantation with survival in patients with long dialysis exposure. Clinical Journal of the American Society of Nephrology, 12(12), 2024-2031.
Thank you all for your fruitful contribution. Feel free to add to it and press “complete”.
what a great topic to dicuss
lets think clinically and critically
you have patient need a kidney and you have to decide a lot of issues
you have scale use four items which is age/hypertension/s.creatinine/cerebrovascular stroke……is this enough to decide this graft is bad???
KDPI numerical measure that combine ten factors which is (age,height,weight,ethnicity,hx of hypertension,hx of DM,cause of death,serum creatinine,hepatitis c and donation after circulatory death
I think ten module is better than four
ok….to how strong the association between KDPI and graft survival
the predictive power is moderate
what that mean>>>>that mean you should not certain number equal good graft and below it is usually bad and this scale has a lot of limitation like(duration of hypertension,duration of diabetis,state of virus c activity,smoking,malignancy,other infections other than virus c and gender)
so should I neglect it
I think it can be used to evaluate relative risk in relation to reference population
also and that was its primary purpose was for “longevity matching” concept into kidney allocation system>>>>candidate with longer estimated post transplant longevity receive priority for graft KDPI of 20% and vice verca
can KDPI expect graft survival>>>>> I think graft survival not related only for the donor criteria but also the recipient but there is moderate predictive power as I mentioned before
finally I should also comment on is older patients is candidate for kidney with KDPI more than 80%
i think the answer is yes and no
yes because as I mentioned longevity matching
no if he has better opportunity if he is on top of the list and he is completely fit and he possible will life longer
so individualize is my answer
Thanks, Ramy for your reply
This is a great reflection, but you need to follow the academic writing style. The answer should be structured in heading and subheadings. Also, there is a lot of “I think” in your reply. You need to substantiate your answer with evidence.
I admire the reflection and writing in your own words.
Thanks professor Halawa
I will surely do
The Scientific Registry of Transplant Recipients define ECD kidneys as: (1)kidneys from deceased donors aged 60 years or above, or
(2) donors aged 50–59 years with at least two of the
following
cerebrovascular accident as the cause of death, terminal or
serum creatinine >1.5 mg/dL or
a history of hypertension.
The designation of SCDs or ECD is binary, but in reality,
there is a continuum.So to fine-tune the SCD/ECD criteria kidney donor profile index is used which is a numerical value.The Kidney Donor Risk Index (KDRI) for a deceased donor is used to calculate the KDPI.The Kidney Donor Risk Index (KDRI) is a calculation that compares the relative risk of post transplant kidney graft failure from a deceased donor’s to a reference donor. In the original KDRI report, the reference donor was 40 years old, non-diabetic. To create the scaled (or “normalised”) form of KDRI presented in DonorNet®, the median (50th percentile) donor was used as the reference donor.
The following donor characteristics are used to calculate the KDRI:
Age
History of Diabetes
Height
Cause of Death
Weight
Serum Creatinine
Ethnicity
Hepatitis C Virus (HCV) Status, from serological or NAT testing
History of Hypertension
Donation after Circulatory Death (DCD) Status
Lower KDPI is associated with longer predicted survival, while higher
KDPI (more than 80) is associated with shorter predicted
survival for the aggregate population.
A Guide to Calculating and Interpreting the Kidney Donor Profle Index (KDPI) Updated: March 23, 2020
Expanded criteria donors in deceased donor kidney
transplantation – An Asian perspective
Ziting Wang*, Pradeep Durai, Ho Yee Tiong
selection criteria –
Remuzzi et al used histology-based selection criteria to assess the quality of ECD kidneys and determine whether they should be implanted single or dual. The kidneys of a donor were obtained, and histopathological examinations were performed.The severity of chronic changes was used to assign a score. Changes in four separate renal tissue components,
vessels
glomeruli
tubules
connective tissue
were scored separately from 0 to 3.
Kidneys with global scores of 0–3 were implanted singly, and
those with scores of 4–6 were considered for dual implants;
those with a score of seven or greater were discarded.
Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective-Ziting Wang, Pradeep Durai, Ho Yee Tiong
For explant biopsy, Vathsala compared the efficacy of KDPI with the Remuzzi score and found that the Remuzzi score was superior in prognosticating graft results in the short term.For improved risk stratification, they concluded that explant biopsies should be performed frequently for patients with KDRI > 1.1.
Vathsala A. Explant biopsy and Remuzzi scoring outperforms Kidney
Donor Profile Index (KDPI) in selection of extended criteria donor
kidneys for single implant. Transplantation 2018;102:1200‑2
Extended Criteria Living Donors should consider donor age, GFR, BMI, impaired glucose tolerance and smoking history.
in the study Donors were divided in two groups: donors without risk factors (RF) and donors with at least one RF. RF were defined as age over 60 years, arterial hypertension, active nicotine abuse and BMI over 30kg/m2.Allografts from high-risk donors had poorer graft function in the first year, according to the findings of the study. Only those beyond the age of 60 had a reduction in the survival of grafts As a result an expansion of criterion for living kidney donors could help to improve the current situation of organ shortage. A thorough preoperative evaluation and allocation of donors and receipients is absolute essential.
Extended Criteria Donors in Living Kidney Transplantation Including Donor Age, Smoking,Hypertension and BMI-Henning Plage, Poline Pielka,Lutz Liefeldt, Klemens Budde,Jan Ebbing, Nesrin Sugünes,Kurt Miller,Hannes Cash,Anna Bichmann, Arne Sattler, Katja Kotsch,
Frank Friedersdorff.
Expanded Criteria Donor (ECD)
It tool was developed to use kidneys with suboptimal characters, in an attempt to increase the availability of donor pool.
This includes kidneys from donors with:
1- Age ≥ 60 years
2- Age 50 – 59 with at least 2 of the following:
· History of hypertension
· S.cr > 1.5 mg/dl
· Cerebrovascular accident as the cause of death.
Kidney donor profile index (KDPI):
Because the quality of deceased donor kidney is an important issue in transplantation, KDPI had been done to assess it, to decide whether to discard the kidney, and to predict the outcome of the allograft after transplanting it.
To determine KDPI, first, need to calculate the donor’s kidney donor risk index
donor characters used to calculate the KDRI are:
· age,
· H/O DM,
· Height,
· weight.
· Cause of death,
· s cr,
· ethnicity,
· HCV status,
· H/O hypertension,
· donation after circulatory death status (DCD)
KDPI is a simple map of the KDRI, a measure of relative risk to a cumulative percentage scale. Take values between 0% – 100%. A donor with a KDPI of 0% has less than all donors in the reference population.
KDPI of 20% means the donor has a KDRI exceeding at least 19% and at most 20% of all donors in the reference population.
In general, a donor with a KDPI of X % means that the donor’s KDRI is more than (X─1)%, but not more than X% of all donors in the reference population.
It is displayed in donor Net
· Yes, I will offer for older > 60 yrs
ECD has inferior outcomes compared to the kidney from donors that do not meet the ECD definition. They can be carefully utilized for selected patients example older patients with a long waiting time of 4 or more years as they show better survival and quality of life than dialysis.
References:
1. Park WY, Kim JH, Ko EJ, Min J-W, Ban TH, Yoon H-E, et al. Impact of Kidney Donor Profile Index Scores on Post-Transplant Clinical Outcomes Between Elderly and Young Recipients, A Multicenter Cohort Study. Sci Rep [Internet]. 2020 Apr 24;10(1):7009. Available from: https://pubmed.ncbi.nlm.nih.gov/32332846
2. Wang Z, Durai P, Tiong HY. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian J Urol [Internet]. 2020/04/07. 2020;36(2):89–94. Available from: https://pubmed.ncbi.nlm.nih.gov/32549658
3. Graft M, Estimates S, Donor D, During AT. A Guide to Calculating and Interpreting the Kidney Donor Profile Index ( KDPI ) Figure 1 . Kaplan − Meier Graft Survival Estimates for Adult, Deceased Donor, Kidney − Alone Transplants During 2008 − 2018 by KDPI. 2020;1–11.
Expanded criteria donor in deceased donation is defined as those with age more than 60 years or age more than 50 years with 2 additional risk factors : terminal serum creatinine more than 1.5 mg/dl , history of hypertension, cerebrovascular cause of death.
Standard criteria donor SCD in deceased donation are those deceased donors who did not meet the criteria for ECD.
The expanded criteria donor is associated with 70% increased risk of graft loss when compared to SCD. But the risk may decrease is certain high risk patient characteristics. For example, in elderly (age>65 years) , the the life expectancy with ECD was 5.3 years compared with 505 years for SCD.
Elderly patients > 65 years, diabetics , long time on waiting list , patients with high PRA, may benefit from ECD , to decrease their time on waiting list, since survival in these patients will not not differ so much if they receive ECD or SCD.
References:
(1) Jesse D. Schold and Herwig-Ulf Meier-Kriesche Which Renal Transplant Candidates Should Accept Marginal Kidneys in Exchange for a Shorter Waiting Time on Dialysis?Clin J Am Soc Nephrol 1: 532–538, 2006. doi: 10.2215/CJN.01130905.
(2) Maggie K.M. Ma, Wai H. Lim, Jonathan C. Craig, Graeme R. Russ, Jeremy R. Chapman, and Germaine Wong Mortality among Younger and Older Recipients of
Kidney Transplants from Expanded Criteria Donors
Compared with Standard Criteria Donors Clin J Am Soc Nephrol 11: 128–136, 2016. doi: 10.2215/CJN.03760415
Criteria of ECD of deceased donor:
Age >60.
Age 50 – 59 with two or more of the following:
· High blood pressure.
· S. Cr>133 μ mol/L (1.5mg/dL).
· Cerebrovascular cause of death
I will offer marginal kidneys to those who has been in long waiting list, no suitable living donor, aged more than 50 and whom has comorbidies. I would preserve SCD for those who are young and better QoL. SCD generally better in graft and patients survival compared to those ECD. The benefits of ECD in those over 65 still debatable, which need more studies to prove. ECD vs SCD benefits also differs between Europe and USA where Europe has more or less narrow differences in patient -graft survival , patient survival, death censored graft survival between SCD and ECD. but USA showed vast differences among SCD and ECD.
Reference(s)
Querard, A., Foucher, Y., Combescure, C., Dantan, E., Larmet, D., Lorent, M., Pouteau, L., Giral, M. and Gillaizeau, F., 2016. Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis. Transplant International, 29(4), pp.403-415.
Hellemans, R., Kramer, A., De Meester, J., Collart, F., Kuypers, D., Jadoul, M., Van Laecke, S., Le Moine, A., Krzesinski, J., Wissing, K., Luyckx, K., van Meel, M., de Vries, E., Tieken, I., Vogelaar, S., Samuel, U., Abramowicz, D., Stel, V. and Jager, K., 2021. Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort. Nephrology Dialysis Transplantation, 36(5), pp.918-926.
This Belgium cohort ( Eurotransplant waitlist) analysed the long term outcome after renal transplantation vs dialysis
– Showed that even at the age more than 65 had a survival benefit with transplantation at least with SCD kidney
– Outcome less favourable when older patients with ECD kidneys.
– Did not showed a statistically significant difference in survival between older patients received and ECD kidney vs those remaining on dialysis – but there is a trend favouring ECD
– Found that ECD transplantation was associated with a higher mortality risk post transplantation compared SCD – may result from an increased risk of poor or delayed graft function
–
Rao PS, Merion RM, Ashby VB et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipient
– Found that survival benefit from transplantation even if the recipient is more than 70 with ECD.
Gill JS, Schaeffner E, Chadban S et al. Quantification of the early risk of death in elderly kidney transplant recipients. Am J Transplant 2013; 13: 427–432
– The risk different according to comorbidities and donor type.
Two studies in France and Catalonia
1. savoye e, tamarelle d, chalem y et al. survival benefits of kidney trans- plantation with expanded criteria deceased donors in patients aged 60 years and over. transplantation 2007; 84: 1618–1624
2. LloverasJ,ArcosE,ComasJetal.Apairedsurvivalanalysiscomparinghe- modialysis and kidney transplantation from deceased elderly donors older than 65 years. Transplantation 2015; 99: 991–996
– Showed survival benefit with transplantation even in older recipient even with the use of ECD
Study by Peters-SengersH,BergerSP,Heemskerk Metal.Stretchingthelimits Of renal transplantation in elderly recipients of grafts from elderly deceased donors. J Am Soc Nephrol 2017; 28: 621–631
– Showed no benefit in survival in patient with >65 transplanted with older donor
– Showed no difference in 5 year survival between DBD or DCD even in patient >65 received from >65 donor
Its not easy to interpret those results due to heterogeneity in population and varying methodology.
Expanded criteria donor (ECD) is an old lexicon for marginal kidney that is defined as a deceased donor older than 60 years or aged 50-59 years with two additional risk factors consisting of a history of hypertension, death as a result of cerebrovascular accident or an elevated serum Cr. ECD is related to lower graft survival than SCD. For allocation patients for kidney transplantation, it is better to utilize Kidney Donor Profile Index (KDPI) and Expected Post Transplant Survival (EPTS). KDPI score is an estimation of kidney allograft quality and factors determining it are age, height and weight, ethnicity/race, history of diabetes, cause of death, serum Cr, DCD. In contrast, the EPTS score estimates how long the candidate will need a functioning kidney and it’s determining factors are age, current diabetes status, number of previous transplants and receiving chronic dialysis. A KDPI of 20% means that the kidney will have function longer than other 80% of available kidneys for donation and a EPTS score of 20% means that the candidate needs a functioning kidney longer than 80% of other candidates. It is important to match KDPI score and EPTS score for allocation of patient for transplantation. For example, kidneys with a KDPI score ≤ 20% first will be offered to patients with an EPTS score ≤ 20%. KDPI scores ≥ 85% are similar to ECD and should be used for older patients, those who cannot stand on dialysis for an extended duration and those with high EPTS.
Extended Criteria Donors in Living Kidney Transplantation Including Donor Age, Smoking, Hypertension and BMI
There was a retrospective single-centre study analysed 158 patients with living kidney transplants performed between February 2006 and June 2012. They investigated the influence of donor risk factors (RF) including body mass index over 30 kg/m2, age > 60 years, active nicotine abuse and arterial hypertension on postoperative kidney function with focus on the recipients. This was measured for long-term survival and glomerular filtration rate (GFR) in a 5-year follow-up.
The result was out of 158 living donors, 84 donors were identified to have no risk factors, whereas 74 donors had at least one risk factor. They noted a significant higher delayed graft function (p=0.042) in the first 7 days after transplantation, as well as lower GFR of recipients of allografts with risk factors in the first year after transplantation. In long-term results, there was no significant difference in the functional outcome (graft function, recipient and graft survival) between recipients receiving kidneys from donors with no and at least one risk factors. In the adjusted analysis of subgroups of different risk factors, recipients of donors with “age over 60 years” at time of transplantation had a decreased transplant survival (p=0.014).
In Conclusion: Eexpanded criteria living donors (ECLDs), could improve access for many patients diagnosed with ESKD. ECLDs should consider donor age, GFR, BMI, impaired glucose tolerance and smoking history. Moreover, in living donors the kidneys vascular supply could influence recipients’ outcome. A detailed evaluation of these risk factors and comorbidities is therefore essential to maintain donor safety as the mentioned risk factor are associated with increased rates of perioperative nephrectomy complications.
The authors: Henning Plage,1 Poline Pielka,1 Lutz Liefeldt,2 Klemens Budde,2 Jan Ebbing,3 Nesrin Sugünes,1 Kurt Miller,1 Hannes Cash,1 Anna Bichmann,4 Arne Sattler,5 Katja Kotsch,5 Frank Friedersdorff1
DOI https://doi.org/10.2147/TCRM.S256962 published August 2020
marginal kidney (ECD )comes from a deceased donor older than 60years or aged 50-59 years with 2 additional risk factors including a history of hypertension, death as a result of cerebrovascular accident, or elevated serum creatinine. It increases the donor pool.ECD is about 15% of deceased donors and has a 70% increased risk of failing within 2 years is compared with a standard criteria donor kidney. It is commonly offered for an older patient with a short survival time and cannot withstand dialysis for an extended period.
Types of marginal donors:
1. complex living donor
2. Non –heart beating donor
3. deceased or cadaveric donor.
Kidney donor profile index (KDPI): the variables used to determine it:
Age Height and weight
Ethnicity/race History of hypertension
History of diabetes Cause of death
Serum creatinine HCV status
Donors meet DCD criteria
Expected Post-Transplant Survival (EPST) factors:
Age Current diabetes status
Number of previous transplants Receiving chronic dialysis
KDPI scores≥85 are similar to ECD and appear to be viable for transplant inappropriate recipients and those recipients with high ESPT scores.
Gopalakrishnan et al.: Marginal kidney donor (http://www.indianjurol.com on Thursday, January 14, 2016, IP: 75.101.1)
Danovitch G.M handbook of kidney transplantation sixth edition.
since art of transplantion had started, scientist are searching to expand the pool of candidates.and they started to think how can we utilize descased kidnies, in fact that the new era of immnosuprresion with cnis and antimetaboiltes had raisen the possibilties of such sucess.
IN 2014 KAS (KIDNEY ALLOCATION SYSTEM) INTRODUCED IN PRACTICE KDPI, , AND ALSO EPTS (EXPECTED POST TRANSPLANT SURVIVAL), THE FIRTS FOR THE DONOR AND THE LATER FOR THE RECPIENT.
KDPI (kidney donor profile index) was the scheme that they relay on to select such donors , and it depends on alot of factors like (age , height, weight,htn, diabetes, cause of death, serum creat, hcv status ).
high kdpi means poor kidney function.in another treminology if the donor has kdpi of 60% that means that the kidney is likely to function longer than 40% of other avilable kidnies .
EPTS , IT HAS MANY FACTORS LIKE(AGE , CURRENT DM, NUMBER OF PREVOIUS TRANSPLANT, IS HE ON CHRONIC DIALYSIS OR NOT.
THE LOWER THE EPTS THE HIGHER POST TRANSPLANT SURVIVAL.
MARGINAL KIDNEY DONORS OR OLD TERMINOLOGY AS ECD KIDNEIES, WHAT DOSE IT MEAN?
IT MEANS DONATION FROM DECASED KDINEY DONOR WITH AGE MORE THAN 60 OR AGE BETWEEN 50-59 WITH TWO RISKFACTORS HTN OR DAETH DUE TO CERBRO VASCULAR STOKE OR ELEVATED TERMINAL SERUM CREAT MORE THAN 1.9.
in fact we have to ask many questions befor offering this kidney to a ckd pt .
1-what is his age
2-cause of his ckd
3-comorbidites htn, dm, ihd
4-bmi
5-tranplanted befor or not
6-what is his cPRA
all this questions will let us know what is suitable for him.
.
SO , IF THE DONOR HAS A HIGH KDPI WE CAN OFFER IT TO RECIPENT WITH HIGH EPTS .AND VICE VESRA, THIS IS A SIMPLE WAY TO UNDERSTAN HOW DECESED KIDNIES ARE ALLOCATED.
Regarding the definition of marginal kidney donor , the exact definition isn’t set yet , i believe it entails those who were not eligible or those who where instantly rejected in the past , those of old age 65-70 years old , those with HTN , females in the child bearing period , GFR of 60-90 ml/min/1.72m , Albumin excretion ratio of 30-100mg/day , obesity BMI 35-40 KG/m , and afraid to say that diabetes as well although written in the absolute contraindications of the OPTN , but the European society and the British transplantation society rarely include thorough ex. and investigations about the risks , comorbidities and survival of the graft . Extended criteria donor include the “Grey zone ” are of potentiality of the donor , before this term wasn’t actually present but recently the need for more donors and the waiting lists of the recipients encouraged experts and health care individuals to include some of those donors on the edge of the “NO” for the good , Provided that should be based on studies , through history, examination , thorough counseling and care about the risks for the donor.
Yes, i believe we can adopt the idea of marginal donors through “individualization”.
*HTN if controlled less than 140/90 by one or 2 drugs ( as many centers believe ) with no other “marginal ” criteria , it would be acceptable .
*any diabetic donor is to be excluded ( i”ll go with the OPTN ) in this one .
*GFR more the 80 .
*Age till 65 , as delayed graft function and decreased graft survival in older than 70 years donors is suspected .
*BMI to be decreased from 40 to 30 and from 35 to 30 before donation .
i believe Tailoring the Criteria according to different settings including the recipient is vital and improves the decision quality.
References:
Donor in the Child bearing period is better not to concept after donation due to possible risks of eclampsia and preeclampsia , and this should be individualized as well according to the comorbidities , obesity , etc.
If we are talking about life donors, it is better to wait for 3 months after donation. Usually, they wait longer. Pregnancy is not contraindicated. I defer the discussion till later. You will have extensive materials about living donation and pregnancy.
ok dear prof.
Thank you, Mohamed, insightful response.
Making an individual decision is the best strategy
Is there a specific approach for an obese donor?
Is there a specific approach for an obese donor?
Morbid obesity (most commonly defined as body mass index (BMI) >35 kg/m2) is considered a relative contraindication for living kidney donation (1).
Pretransplantation loss of weight is recommended. Additionally, a healthy lifestyle (eg, exercise, healthy diet, tobacco abstinence) should be encouraged post-donation (1).
References:
1) Krista L Lentine, and John Vella. Kidney transplantation in adults: Evaluation of the living kidney donor candidate. © 2021 UpToDate. (Accessed on 11 November 2021).
pre and post transplant weight control is advised and recommended by the OPTN , BMI more then 35 to 40 is considered as a relative contraindication and should be taken in context of other comorbidities and general well being
Another question; Did you ever think of the term expanded criteria live donor!? Please write your thought about who could be an EC live donor? Why we are looking for such donors if ever?
Dear Dr Alaa,
As explained in the previous contributions, the expanded criteria donor (ECD) describes a donated kidney with suboptimal characteristics. ECD is increasing rapidly to expand the available donor pool by including more organs that were previously not accepted for donation (1).
When applying the same principles to the living donation process, we will face the ethical challenge of causing no harm to the donor. The donor with systemic or isolated kidney disease making it suboptimal is undoubtedly at risk of developing a variable degree of chronic kidney disease up to renal failure by himself.
Even in healthy donors, we should not forget that kidney donation carries a small but actual risk of developing kidney disease (2).
References:
1) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
2) Muzaale AD, Massie AB, Wang MC, et al. risk of end-stage renal disease following live kidney donation. JAMA. 2014 Feb;311(6):579-86.
Thank you, please elaborate more. How science and ethical conduct of practice could meet in such a session?
My own understanding from my reading is that OPTN has defined some absolute contraindications for living kidney donation that includes diabetes mellitus and hypertension with evidence of end-organ damage (1).
I believe the rationale behind this is to avoid loss of the viable nephron mass (by unilateral nephrectomy) in a person who already suffers from subclinical loss of active nephrons. Furthermore, he is at risk of developing kidney disease in the future secondary to his underlying kidney disease. Here, the situation is different from retrieving the kidney from a deceased donor when we will only evaluate the benefit of this marginal kidney to the proposed recipient.
References:
Organ Procurement and Transplantation Network: Policies. http://optn.transplant.hrsa.gov/governance/policies (Accessed on 10 November 2021)
elderly donors, Diabetes, HTN, kidney stones & kidney cysts are considered marginal living donors
Because graft survival is better from living donor than deceased donors as living donors have limited ischemia time, better organ quality, and no inflammation (which occur after brain death)
graft survival from marginal living donors is similar to that of standard deceased donor but less than that of standard living donor
The potential harm to the donor is the ethical concern, presence of comorbidities, renal impairment after donor nephrectomy
System UR. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive; 2013.
Moore DR, Serur D, Rudow DL, Rodrigue JR, Hays R, Cooper M; American Society of Transplantation. Living Donor Kidney Transplantation: Improving Efficiencies in Live Kidney Donor Evaluation–Recommendations from a Consensus Conference. Clin J Am Soc Nephrol. 2015 Sep;10(9):1678–86
Englum BR, Schechter MA, Irish WD, Ravindra KV, Vikraman DS, Sanoff SL, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation. 2015 Feb;99(2):309–15.
I have 2 questions for you;
Dear all, Thanks a lot for your responses.
In your answers, please specify that the term ECD is for a Deceased Donation.
Define what is the difference between SCD and ECD, and how this affects the outcome.
Then justify your decision in accepting it or not.
Dear All
Thank you for this interesting discussion, really enjoyable.
Will you accept a kidney from a diabetic deceased donor?
If yes, what are your selection criteria?
This is a good and tricky question. It need knowledge about graft survival of DM donor, NonDM donor(DM donor with low KDPI, DM donor with high KDPI(>85%), non DM donor with low KDPI, Non DM donor with high KDPI)compared with waiting list for years.
great question to test the knowledge.
if I have a patient more than 40 years old on long waiting list without a suitable living donor, will consider to accept Diabetic deceased donor, provided low KDPI DM kidneys.
Here is why,
Jordana B cohen evaluated Survival benefit of transplantation with deceased diabetic donor kidney compared with remaining on the waitlist
– Study had median follow up of 8.9 years
– Patient who had received a diabetic donor kidneys Compared with patient who either remained on waiting list or received non diabetic donor kidney had decreased cumulative hazard of all cause mortality
– When KDPI taken into consideration – comparing with remaining in waiting list or transplantation with a non DM low KDPI kidneys, recipients DM of low KDPI kidneys and non DM high KDPI kidneys had significant lower HR of mortality
– Recipient of Diabetic high KDPI had no reduction in mortality
– age below 40 years at the time transplant had no reduction in mortality from accepting Diabetic donor kidney
Kidneys from donors with DM have frequently been refused for graft due to the possibility of presenting diabetic nephropathy, one of the main complications of this disease. However, with the increased need for organs for transplantation, the demand for kidneys from potential deceased donors has also increased, including diabetic deceased patients. A study of 2,300 kidneys from deceased diabetic donors (DDD) recipients concluded that the survival of these grafts was significantly lower (17%) when compared to non-diabetic donor grafts. It also concluded that there was no statistical difference in the mortality of these patients. A more recent work concluded that, after six months of transplantation, seven of nine patients with DDD grafts (77%) showed creatinine values from 1.3 to 2.4 mg/dl, meaning a good graft function.
For me, yes I would accept DDD, probably for the elderly and patients with multiple comorbidities.
References
1. Ahmad M, Cole EH, Cardella CJ, Cattran DC, Schiff J, Tinckam KJ, et al. Impact of deceased donor diabetes mellitus on kidney transplant outcomes: a propensity score-matched study. Transplantation. 2009; 88: 251-260.
2. Wolters HH, Brockmann JG, Diller R, Suwelack B, Krieglstein CF, Senninger N. Kidney transplantation using donors with history of diabetes and hypertension. Transplant Proc. 2006; 38: 664-665.
accepting diabetic deceased donor is associated with high mortality in recipient more than non diabetic deceased donor , but anyhow it is better than staying on dialysis. but this is not recommended if recipient is below 40 years of age.
i think pre transplant donor kidney biopsy should be done
Ellen F. Carney. Survival benefit of accepting a diabetic deceased donor kidney. Nature Reviews Nephrology 2017 volume 13, page 444.
1- How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria?
Expanded criteria donor (ECD, or marginal donor) refers to a kidney from a deceased donor aged 60 years or above, or aged 50-59 years with 2 additional risk factors that include: 1/ history of hypertension, 2/death as a result of CVA or 3/ elevated terminal serum creatinine.
In December 2014, the kidney allocation system (KAS) intended to improve graft survival by allocating lower KDPI (kidney donor profile index) scores to lower EPTS (expected post-transplant survival) scores.
Those with KDPI scores> 85% are similar to ECD.
The risk of graft failure within 2 years after receiving ECD kidney was 70% higher than standard criteria kidney (SCK) transplants. Which means in other words while SCK transplant has an 88% 2 year graft survival, an ECD kidney transplant has an 80% graft survival.
The recipient should be informed and consented that ECD kidney transplant doesn’t give superior graft survival outcome if compared to standard criteria donor.
Usually it is accepted for older recipients to receive ECD kidneys from older patients.
There are some benefits of ECD:
1- It can take care of around 12% of the waiting transplant list in ayear.
2- Having an ECD kidney carries a better quality of life and patient survival when compared to dialysis.
3- Future randomized controlled studies could help giving insight into how we could get better outcomes from ECD.
Disadvantages of ECD compared TO standard criteria donation:
1- Less graft survival, more DGT, more rejection, more mortality.
2- Rapid return to renal transplant waiting list, so it gives false decrease of the number on the waiting list.
Immunosuppression after ECD transplantation:
Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that ATG might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on m-TOR inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
Dear All
Thank you for this interesting discussion, really enjoyable.
Will you accept a kidney from a diabetic deceased donor?
If yes, what are your selection criteria?
1- How would you define marginal donor (expanded criteria donor)? Would you offer it to your CKD patients? If yes, what would be your selection criteria?
Expanded criteria donor (ECD, or marginal donor) refers to a kidney from a deceased donor aged 60 years or above, or aged 50-59 years with 2 additional risk factors that include: 1/ history of hypertension, 2/death as a result of CVA or 3/ elevated terminal serum creatinine.
In December 2014, the kidney allocation system (KAS) intended to improve graft survival by allocating lower KDPI (kidney donor profile index) scores to lower EPTS (expected post-transplant survival) scores.
Those with KDPI scores> 85% are similar to ECD.
The risk of graft failure within 2 years after receiving ECD kidney was 70% higher than standard criteria kidney (SCK) transplants. Which means in other words while SCK transplant has an 88% 2 year graft survival, an ECD kidney transplant has an 80% graft survival.
The recipient should be informed and consented that ECD kidney transplant doesn’t give superior graft survival outcome if compared to standard criteria donor.
Usually it is accepted for older recipients to receive ECD kidneys from older patients.
There are some benefits of ECD:
1- It can take care of around 12% of the waiting transplant list in ayear.
2- Having an ECD kidney carries a better quality of life and patient survival when compared to dialysis.
3- Future randomized controlled studies could help giving insight into how we could get better outcomes from ECD.
Disadvantages of ECD compared TO standard criteria donation:
1- Less graft survival, more DGT, more rejection, more mortality.
2- Rapid return to renal transplant waiting list, so it gives false decrease of the number on the waiting list.
Immunosuppression after ECD transplantation:
Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that ATG might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on m-TOR inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.
Reference:
World J Transplant. 2016 Mar 24; 6(1): 103–114.
Published online 2016 Mar 24. doi: 10.5500/wjt.v6.i1.103
ECD defined as deceased donor who is more than 60 years old or 50-59 years old in addition to 2 of the followings:
Because of shortage in available kidneys of living donor or deceased SCD,
A trial to increase pool for donation by accepting “ECD” kidney which represent bad prognostic kidneys for wait-listed dialysis patients.
Subgroups with significant survival benefit after expanded criteria donor kidney transplantation according to epidemiological data
-Patients older than 40 yr
-Long median waiting time (> 4 yr)
-Patients with diabetes or hypertension
-Dialysis patients with vascular access problems
-Dialysis patients whose life expectancy in dialysis is lower than the estimated waiting time for kidney transplantation
The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis.
Although most studies of ECD kidney transplantation confirm lower allograft survival rates, recipients of ECD kidneys generally have improved survival compared with matched dialysis-treated patients.
Kidneys transplanted from ECDs have higher DGF rates, more acute rejection episodes and decreased long-term graft function.
Despite these inferior results, these transplants have definitely survival advantage over dialysis patients remaining on transplant waiting list
-Merion RM, Ashby VB, Wolfe RA, Distant DA, Hulbert-Shearon TE, Metzger RA, Ojo AO, Port FK JAMA. 2005 Dec 7; 294(21):2726-33.
–Pascual J, Zamora J, Pirsch JD Am J Kidney Dis. 2008 Sep; 52(3):553-86.
–Filiopoulos V, Boletis JN. World J Transplant. 2016;6:103–114.
The widening gap between organ supply and demand is progressively increasing the waitlist time for patients seeking kidney transplantation. The increasing need for kidney grafts has led to a progressive expansion in the selection criteria for deceased and living donors (LDs). The terms- ‘Expanded-criteria donors’, ‘Marginal kidney donor’ is not yet clearly defined. It simply means the usage of suboptimal quality cadaveric renal grafts, non-heart-beating donors (NHBD), and living donors with some acceptable medical risks.
Simply, it can be identified as elderly patients or patients with comorbidities that were earlier considered to be unsuitable for donation. According to the US Renal Data System, the most frequent types of marginal LDs are those with older age, diabetes, hypertension, overweight and obesity, nephrolithiasis, malignancies, and kidney cysts. Not only those, but also kidneys that, though collected from standard donors, have complex arterial anomalies (e.g., more than 2 arteries though on a single patch or separated in such a way to need a double anastomosis or a bench reconstruction), kidneys with noticeable parenchymal damage (macroscopic sclerosis areas or sutured polar branches accidentally damaged during removal), and kidneys with complex anomalies of the excretory tract (complete double district), all conditions causing a loss functional mass.
Aging causes a series of morphological and physiological changes to the kidneys leading to an increased glomerular, vascular, and tubular senescence. Such morphological changes can result in significant functional changes including a decrease in renal blood flow and glomerular filtration rate, leading to an overall deterioration in renal function. The progressive loss of the renal mass and the decrease in the total number of functioning glomeruli cause a marked reduction of the functional reserve of the kidney, with the glomerulopenia being at the basis of a “remnant kidney” phenomenon causing progressive allograft failure. Moreover, kidney transplants from older donors are particularly susceptible to the negative impact of long cold ischemic time; a well-known independent risk factor for delayed graft function (DGF) associated with inferior graft survival.
Despite the survival benefits in recipients of marginal kidney transplants being inferior compared with those in recipients of standard criteria donor kidneys, yet, is significantly better than in those remaining on hemodialysis. Economic analysis suggests that transplantation with a marginal donor kidney is more cost-effective than dialysis treatment. Ojo et al. demonstrated that KT with a marginal kidney can increase the life expectancy by 5.1 years over maintenance dialysis treatment.
Older age does not represent a contraindication for living kidney donation. Collini et al. described a series of 38 patients undergoing KT (16 as single and 22 as double transplants) matched for age with donors aged 75 years or older (mean age 79.1 years, range 75–90 years). The 3-year actuarial graft survival rate was 64%, while the patient survival rate was 81.2%, with an acceptable renal function along the study period. Rather than actual age itself, kidney function, the presence of other comorbidities, and overall health should determine whether an older living kidney donor should be included or excluded. Importantly, impaired kidney function and health after donor nephrectomy may be more acceptable for older donors than younger ones because of shorter life expectancy. Similarly, a body mass index (BMI) >35 should not be considered as an absolute contraindication for living kidney donation.
Potential donors should be extensively evaluated and properly informed on the potential risks of donation, they should be aware that in some cases lifetime risks may be difficult to predict. Absolute and relative contraindications to living donation vary greatly across transplant centers worldwide and even nationally. Therefore, the choice to accept a potential donor often becomes subjective.
For me, whether I will be offering marginal donor to my CKD patients if present, yes I will do but for a certain group of patients, e.g., elderly to elderly after explaining all risk factors, patients with hepatitis C to hepatitis C-PCR positive.
References:
1. Cantarelli C, Cravedi P: Criteria for Living Donation from Marginal Donors: One, No One, and One Hundred Thousand. Nephron 2019;142:227-232.
2. Paride De Rosa, Giovanna Muscogiuri, Gerardo Sarno, “Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients”, International Scholarly Research Notices, vol. 2013, Article ID 301025, 8 pages, 2013. https://doi.org/10.5402/2013/301025
3. P. de Rosa, M. Santangelo, A. Ferrara et al., “Suboptimal kidney: the experience of a single transplant unit,” Transplantation Proceedings, vol. 36, no. 3, pp. 488–490, 2004.
Kidney transplantation is the best treatment of ESRD as it improves quality of life and survival compared to Dialysis , but due to increased patients exceeding the donors , so the need to expand the criteria of choosing the donor to reduce waiting list and the gap between the recipients and donors whatever deceased or living donors making them suboptimal donors not standard ..
The American United Network for Organ Shortage decided to accept donation from Extended Criteria Donors (ECD) which replaced the term of marginal kidney for the first time in 1997 by Kauffman , In 2002, a clear definition was given:
Extended criteria donors (ECD ) defined as: donors more than >60 years old or older or age 50-59 years and has at least 2 of three of the following:
*Cause of death is cerebrovascular
*terminal serum creatinine more than 1.5 mg/dl (132.6 µmol/L)
*history of hypertension.
Other definitions of marginal kidneys which have been studied by different authors as fibrosed kidneys based on histopathology, donation after cardiac death (DCD).
In 2019, in Europe, nearly 30% are ECD from potential donors 24% In North America, and nearly 40% of these kidneys are discarded each year .
Why marginal kidney is suboptimal donation
Kidneys from old donor ( aged kidneys ) are more susceptible to ischemia reperfusion injury (IRI).
Aging cells which are present in older kidney which resulting in a decreased tissue regeneration and chronic low level of inflammatory status , also Multiple mechanisms may explain the decreased tolerance to IRI as mitochondrial functions impairment results in reduction in antioxidant defenses, also heat shock protein 70 reduction which responsible for trans mitochondrial transport, and telomere shortening increases the process of aging .
Also hypertension may increase the level of aging cells in the kidney of the donor .
So we can say , the increased level of inflammatory status and edema caused by IRI in old kidneys can result in marked immune response .
Also dendritic cells functions as antigen presenting capacities are increased with age . Dendritic cells role in aging is still not fully understood , Moreover, it was shown that, after acute tubular necrosis (ATN) , the tubular cells showing marked expression of HLA molecules and inflammatory cells accumulation .
On the clinical aspect , delayed graft function which induced by IRI can result in 38% increased risk of acute rejection .
We can conclude That the effect of IRI on ECD kidneys is significant, and using machine of perfusion lowering the rate of delayed graft function and improved kidney survival rate as compared to cold storage .
-I will offer ECD to my CKD patients after explanation of risks ( delayed graft function , acute rejection , increased mortality in the first 200 days post transplant ….) and advantages that improving survival compared to Dialysis patients and written consent is mandatory .
Which patient I will select for ECD :
* older than 60 years.
*Patients with multiple access failure .
*Patients with life expectancy while on dialysis is lower than estimated waiting time for renal transplantation.
Reference:
Noble , J., Jouve , T., Malvezzi , P., et al .(2020). Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation.Frontiers in Immuunology , 10, 1-9.doi: 10.3389/fimmu.2019.03142
I want to add an option that can be used occasionally with ECD kidneys: Double kidney allocation.
The principle is to overcome the weakness of a single ECD kidney profile by offering the patient a chance of transplanting both kidneys en block (obviously, this is applicable only for programs allowing cadaveric transplantation).
The ECD should meet at least two of the following criteria for double kidney allocation to be considered:
– Age of donor more than 60 years.
– History of long-lasting diabetes.
– History of long-lasting Hypertension.
– Serum Cr more than 221 umol/L at time of retrieval.
– Low eGFR (less than 65 ml/min) at time of recovery.
– Glomerulosclerosis more than 15% and less than 50%.
References:
1) John Vella and Daniel C Brennan. Kidney transplantation in adults: Organ sharing. © 2021 UpToDate. (Accessed on 8 November 2021).
To improve shortage in organ transplant donation , more criteria of acceptance is added in what is called expanded donor criteria ,which include using donors at the extremes of age, double kidney transplants from marginal donors, extended-criteria/Kidney Donor Profile Index (KDPI) >85 percent donors, and the use of living kidney donors (1).
Expanded donor criteria is
donor above 60years of age.
or a donor over the age of 50 with two of the following:
a history of high blood pressure, a creatinine greater than or equal to 1.5, or death resulting from a stroke.
We must get written permission from a patient before offering an ECD kidney. The decision to accept an ECD kidney is a personal decision. Accepting an ECD kidney may significantly decrease the amount of time a person waits for transplant.
Reference:
1-Jacobbi LM, McBride VA, Etheredge EE et al the risks, benefits, and costs of expanding donor criteria. A collaborative prospective three-year study. Transplantation. 1995;60(12):1491
marginal donors are borderline donors with less strict criteria. they include donors of older ages than 60 years and those with well-controlled ch. diseases.
I would offer it to CKD pts as it is still better than hemo or peritoneal dialysis.
selection criteria include old ages, pts with ch. viral infections, pts with well-controlled T2DM, HTN, …
Marginal donor is one of the deceased (cadaveric)donor
Their are standard one
Expanded one & marginal
In standard
Age<60
Cause of death no cerebrovascular event
Not diapetic
Last creatinine 60 but no other problems
Or between 50&60 and have any 2 of the following
Diapetic patient
HTN
Cerebrovascular event cause of death
Creatinine >1.5
Marginal criteria
Age>70 without any other problems
Or between 60&70 with
Diapetes
HTN
Proteinuria up to 1 gram
But gfr >50ml/min
Glumerulosclrosis<20% in renal biopsy more than 25 glomeruli
And surely it’s not preferred one
But it better than keep patient on HD (waiting list) as it offer more quality of live and survival
Marginal donor or expanded criteria donor
refers to a less favorable deceased donor who previously would be rejected , but due to shortage in donor pool , these donors now can be used for special patients such as elderly and patients with short life expectancy.(1)
Diagnostic chriteria of ECD
1- Age > 60 y without comorbidity
2- Age (50 -59) with 2 or more
Hypertention
Death from CVA
Last premortem S Cr 1.5 mg/dl.
1- Maggiore, U., & Cravedi, P. (2014). The marginal kidney donor. Current opinion in organ transplantation, 19(4), 372-380.
Marginal donor is the term used to describe kidneys from older donors, those with CVA, or other comorbidties such as type 2 dm, or hypertension. Also , those kidneys with impaired function as creat is 1.97 mg/dL.
The applicability of this option is based on patient to patient analysis. In other words, whether the recipient quality of life is a priority over long term graft survival as in older CKD patients. Also, for patient with HCV or HIV infections , whom may benefit from recipient with similar infections.
Dear All
What is the KPDI?
kidney donor profile index is donor scoring system involves 10 factors , determine donor quality and predict short and long term outcome, used in deceased kidney donor.
these factors age, race, HTN, DM, serum creatinine, HCV status, cause of death, donation after circulatory collapse, weight and height
Kidney Donor Profile Index is a parameter that has been developed to achieve an equal and effective distribution of deceased donor kidney to the get the best survival.
It is calculated using some donor date as age, weight. height and comorbidities. then a result form zero to 100 will be obtained . the lower the better chance of kidney survival.
Kidneys with lowest KDPI is first offered to pediatric waiting list then to adult with lower EPTS.
the following video illustrate it elegantly
https://optn.transplant.hrsa.gov/resources/allocation-calculators/kdpi-calculator/learn-about-kdpi/
The Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney.
These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death.
lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function.
example: KDPI of 20% will have a longer function than 80% of recovered kidney.
on average, a kidney with KDPI<20% lasts 11,5 years
a kidney with KDPI >20% TO <85 % lasts 9 years
a kidney with KDPI > 85% lasts 5,5 years
Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
The Kidney donor profile index(KDPI) is a numerical measure that combines ten clinical and demographic donor factors into a single percentile number that summarizes the quality of the deceased kidney relative to other recovered kidney.
These factors include including age, race, weight and height, history of diabetes and hypertension, serum creatinine, hepatitis C state and cause of death.
lower scores are associated with longer estimated function, while higher scores are associated with shorter estimated function.
example: KDPI of 20% will have a longer function than 80% of recovered kidney.
on average, a kidney with KDPI<20% lasts 11,5 years
a kidney with KDPI >20% TO <85 % lasts 9 years
a kidney with KDPI > 85% lasts 5,5 years
Kidney donor profile index(KDPI) score and the expected post transplantation survival (EPTS score) replaced the old ECD/SCD
Kidney Donor Profile Index (KDPI)
To know about KDPI, first we should know about KDRI (Kidney Donor Risk Index) score.
KDRI assesses relative risk of post-transplant graft failure and depends on:
1) Donor age
2) Race
3) Creatinine
4) Cause of death
5) history of diabetes
6) history of hypertension
7) height
8) weight
9) HCV status
10) NHBD (non heart beating donation)
KDPI is percentage of donors with KDRI score less than or equal to the donor’s KDRI score.
For example, if somebody has KDPT 85%, it means 85% of the donors have KDRI score less than the donor. The higher the KDPI, lower is the expected lifespan of the donated kidney.
disparity between the availability of organs and waiting patients for transplants has forced many transplant centers across the world to use marginal kidneys from marginal donors. Marginal kidney donors can be defined as: all donors older than 60 years, donors older than 50 years with any of the following criteria: (1) hypertension, (2) cerebro-vascular cause of brain death or (3) pre-retrieval serum creatinine (SCr) level > 1.5 mg/dl, with a degree of glomerulosclerosis >15% and prolonged cold ischemia.
Transplantation with marginal cadaveric kidney donor is established. There is published evidence of its better outcome than waitlisted patients on dialysis regarding patient survival and quality of life.
Using a non-heart-beating donors is still in a plateau phase and comprises a minor percentage of deceased donations.
The main concern is primary non-function of the renal graft apart from legal and ethical issues.
There has been an increased use of marginal living kidney donors with some acceptable medical risks with a main concern is the safety of the living donor. There is not enough scientific data available to quantify the risks involved for such donation.
marginal donor can be either Complex living donor ,Non-Heart-beating donor (NHBD) or
Deceased or cadaveric donor
marginal deceased donor emphasizes on the graft being marginal and the only affects recipient outcomes. In the marginal living donor, focus is on the potential harm to the donor. Steiner[1] used the term ‘IMA donors’ for donors with isolated medical abnormalities. But multiple risk factors for future kidney disease may coincide in the same patient.
The term ‘Complex living donor’ used by Resse[2] is probably preferred for all suboptimal donors
The definition of “normal” GFR changes with age and it decreases over time The decrease in GFR is approximately 1 ml/min/1.73 m2 per year after age 40. There is an acute decrease in GFR of approximately 30% after unilateral nephrectomy; however, the impact of unilateral nephrectomy on this rate of decline in GFR is unknown. Acceptable GFR in a donor is that which can be predicted to provide adequate function for both donor and recipient after donor nephrectomy/transplantation. A GFR of ≥80ml/min is generally considered as accepted value although some centers use ≥60ml/min. GFR corrected to the age rather than age itself determines acceptability for donating.Age related physiological changes are also responsible of an increased risk of nephrotoxicity due to medications, including the commonly used immunosuppressive
medications as calcineurin inhibitors (CNIs) cyclosporine and tacrolimus [3].
using age matching of elderly donors and recipients is effective system for organs from elderly donors with good results .
For me i would recommend ECD for a selected number of patient:
•Older patient >55 years old.
•Patient with multiple failed vascular access.
•Patients with waiting time for transplantation more than 4 years.
•young patients with dialysis complications and low expected survival.
1-Steiner R. How should we ethically select living kidney donors when they all are at risk? Am J Transplant. 2005;5:1172–3.
2-Reese PP, Caplan AL, Kesselheim AS, Bloom RD. Creating a medical, ethical and legal framework for complex living kidney donors. Clin J Am Soc Nephrol. 2006;1:1148–53.
3-M. Naesens, D. R. J. Kuypers, and M. Sarwal, “Calcineurin inhibitor nephrotoxicity,” Clinical Journal of the American Society of Nephrology, vol. 4, no. 2, pp. 481–508, 2009.
Marginal donor/ Expanded criteria donor:
Due to a large demand-supply gap between kidney recipients and donors, OPTN (Organ Procurement and Transplantation Network) defined ECD (Extended Criteria Donor) as a brain dead donor aged more than or equal to 60 years OR between age 50 to 59 years with at least 2 out of the 3 conditions, namely, history of hypertension, a terminal serum creatinine of >1.5 mg/dl , or a cerebrovascular cause of death. (1)
The term ECD was originally coined in context of deceased donor program, the main aim being to reduce the rate of discarding kidneys as it has been shown that getting a transplant from ECD is better than remaining on dialysis. (1,2)
The term marginal donor is a better term, which will include: (3)
a) Marginal cadaveric kidney donor
b) Non Heart Beating donor (NHBD) or Donation after Circulatory Death (DCD)
c) Complex living donor
a) Marginal cadaveric kidney donor is the donor defined as ECD by the OPTN.
b) NHBD/ DCD is a donor who has sustained irreversible brain injury and has been declared dead after cardiac asystole. Such donors do not fit into the criteria of brain-dead donors. These kidneys have a prolonged warm ischemia time. Hence their results are suboptimal.
c) Complex living donor is a living donor who does not fit in the standard living donor guidelines. Such a donor may include medical risk factors like age more than 65 years, family history of ESRD in first degree relation, family history of Diabetes in a first degree relative, impaired fasting glucose, hypertension, dyslipidemia, obesity, hematuria, proteinuria, renal stones, borderline normal GFR etc. (4,5)
Would you offer it to your CKD patients?
Yes. Data has shown that getting a marginal donor transplant is better than remaining on a wait-list. (1,2)
Although this would be an informed choice by the prospective recipient
References:
1) Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005;294:2726-2733.
2) Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol 2001;12:589-597.
3) Gopalakrishnan G, Gourabathini SP. Marginal Kidney Donor. Indian J Urol 2007;6-293.
4) Reese PP, Caplan AL, Kesselheim AS, et al. Creating a medical, ethical and legal framework for complex living kidney donors. Clin J Am Soc Nephrol 2006;1:1148-53
5) Umberto M, Paolo C. The marginal kidney donor. Curr Opin Organ Transplant 2014;19:372-380
ECD kidneys are those either from
1-a deceased donor ≥ 60 years of age,
2-or a donor 50 to 59 years of age with at least two of the following features:
history of hypertension, terminal serum creatinine > 1.5 mg/dL (133 mmol/L), or cerebrovascular cause of death
3-non heart-beating donors.
4-HCV donor
now KDPI replaced (SCD AND ECD) and based on :
age, height, weight, ethnicity,h\o of Hypertension or DM, causes of death, terminal creatinine, Hep (C) status and donated a kidney after circulatory death.
a kidney with a KDPI OF < 20% based on calculated factors should survive longer than 80% of the previous years harvested kidney.
on average, a kidney with KDPI<20% for the last 11,5 years
a kidney with KDPI >20% TO <85 % LAST 9 YEARS
a kidney with KDPI > 85% LAST 5,5 YEARS
upon that, patients who previously would only accept an SCD kidney would default to accepting a kidney with a KDPI OF <85%
Expanded criteria donors for kidney transplantation. Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Am J Transplant. 2003;3:114–125
United Network of organ sharing.
How would you define marginal donor (expanded criteria donor)?
The expanded criteria donor (ECD) is any donor over the age of 60, or a donor over the age of 50 with two or more of the following: hypertension, creatinine greater than or equal to 1.5, or death resulting from a CVA. Kidney donation from deceased donor due to CVA is considered in the ECD because the majority of CVA are ischemic in origin resulting from rupture of atherosclerotic plaque which indicates vascular disease, renal vessels in this case are not exception. Hemorrhagic CVD could also result from hypertensive emergencies in which renal vessels are also implicated.
Large retrospective studies have showed higher rate of delayed graft function, episodes of acute rejection in the first year and lower graft survival of ECD comparing with SCD. However,when comparing ECD with waitlisted patients on dialysis, there was improvement in life expectancy.
Would you offer it to your CKD patients? If yes, what would be your selection criteria?For my patient, marginal kidney could be offered if patient satisfies following criteria.
The selection criteria for EDC would be with Older patients, although recent Belgian cohort suggested that older patients might gain a survival benefit with SCD versus dialysis, but any survival benefit with ECD transplantation may be small, comorbid patients who are hypertensive and or diabetic patients, patients with vascular access problems, patients with low immunological risk patients, long median waiting list> 4 years ,KPDI 85 or higher % beside, dialysis patients whose life expectancy on dialysis is lower than the estimated time for renal transplantation.
The transplant center must get written permission from a patient before offering an ECD kidney. The decision to accept an ECD kidney is a personal decision. Accepting an ECD kidney may significantly decrease the amount of time a person waits for transplant.
Expanded Criteria Donor (They are also referred to as donors with “medical complexities”.ECD donors are normally aged 60 years or older, or over 50 years with at least two of the following conditions hypertension history, serum cr.>1.5 mg/dl or cause of death from cerebrovascular accident.
The use of organs from “marginal” or expanded criteria donors (ECD) has increased the pool of kidneys available for kidney transplantation.Recipients of these kidneys have a relative risk of graft loss greater than 1.70 compared with kidneys from a reference group of donors aged 10–39 years without any of the other three conditions. Recipients of ECD kidneys experience a survival benefit from transplantation when compared with candidates who remain on the waiting list .
study of Rochel suggest that older patients might gain a survival benefit with SCD transplantation versus dialysis, but any survival benefit with ECD transplantation versus dialysis may be small.
Reference
Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort
Rachel Hellemans, Anneke Kramer, Johan De Meester, Frederic Collart, Dirk Kuypers, Michel Jadoul, Steven Van Laecke, Alain Le Moine, Jean-Marie Krzesinski, Karl Martin Wissing … Show more
Nephrology Dialysis Transplantation, Volume 36, Issue 5, May 2021, Pages 918–926, https://doi.org/10.1093/ndt/gfab024
ECD is defined as :
I would offer my patient ECD kidney after informed consent. I would let him know that having ECD kidney might be associated with a higher possibility of temporary dialysis or graft loss, but in the other side ECD kidney found to be associated with superior survival when compared to keeping on dialysis, adding to that ECD kidney may shorten the time a recipient waits for transplant.
My Selection Criteria Will Be:
Types of marginal donor (ECD)
1.Complex living donor
Type of risk factor & Example
• Evidence of current renal disease
eg:Hematuria, proteinuria, nephrolithiasis
• Direct risk for CKD
eg:Hypertension, obesity
• Reduced nephron mass
Age ≥65 years
• Genetic risk factor
Family h/o of ESRD in 1st relative
• Risk factor for a CKD
Diabetes in a first-degree relative, Impaired fasting glucose
• Cardiovascular risk factor
Smoking, hyperlipidemia, hypertension
• Other
Black race, sickle trait
• Combination of previous risk factors
Hypertensive black patient
Indian J Urol. 2007 Jul-Sep; 23(3): 286–293.
Marginal kidney donor
Ganesh Gopalakrishnan and Siva Prasad Gourabathini
2.Non-Heart-beating donor (NHBD)
The NHBD is a donor who has suffered an irreversible brain injury.
Many transplant centers are reluctant to use kidneys from NHBDs due to relatively higher incidence of primary nonfunction (PNF). Issues like uncertainty regarding diagnosis of death on the basis of cessation of cardiac activity (cardiac death), logistics of family consent involved in the procurement of organs and prolonged warm ischemia all contribute to its slow development. It is important to educate the public, hospitals and physicians about the possibilities of organ donation from NHBDs. Public trust is most important in the success of any transplant program.
Indian J Urol. 2007 Jul-Sep; 23(3): 286–293.
Marginal kidney donor
Ganesh Gopalakrishnan and Siva Prasad Gourabathini
3.Deceased or cadaveric donor
In a consensus statement, an international panel of pathologists presented a methodology to assess the marginal kidneys based on the viable nephrons to guide about single or dual transplantation or discard the organ.This panel suggested a biopsy-based scoring system for kidneys, with scores ranging from a minimum of 0 (indicating the absence of renal lesions) to a maximum of 12 (indicating the presence of marked changes in the renal paren-chyma). Kidneys with a score of 3 or lower were predicted to contain enough viable nephrons for single transplants. Those with a score of 4, 5 or 6 could be used as dual trans-plants, on the assumption that the sum of the viable nephrons in the two kidneys approached the number in one ideal kidney. Kidneys with a score of 7 or greater were discarded, since it was assumed that they would not deliver sufficient number of nephrons, for even dual transplanta-tion.
(*) Remuzzi G, Grinyo J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. J Am Soc Nephrol. 1999;10:2591–8. [PubMed] [Google Scholar]
Pirani CL, Salinas-Madrigal L. Evalua-tion of percutaneous renal biopsy. In: Sommers SC, editor. Kidney pathology de-cennial, 1966–1975. New York: Appleton-Century-Crofts; 1975. [Google Scholar]
The very long transplant waiting lists has led to the use of expanded criteria donor kidneys in an effort to increase the donor pool
ECD referes to donors with suboptimal criteria
Expanded criteria donor is a donor characterised by :
1) age above 60
2) age from 50-59 with 2 of the following:
*hypertensive
*creatinine 1.5 or higher
* brain death from cerebrovascular event
Marginal donors aalso include diabetic patients , the non-heart-beating cadaver donors, or those with anatomical abnormalities
Incidence of graft loss is higher with expanded criteria donors , some physicians may proceed to dual kidney transplant to overcome this probleme
Expanded criteria donor greatly shortens waiting time on transplant lists , and survival of patients transplanted using ECD is better than staying on dialysis
Patient should be informed and consenting before being transplanted using ECD kidneys .
It may be very beneficial to recipients with expected short life spans
F. K. Port, J. L. Bragg-Gresham, R. A. Metzger et al., “Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors,” Transplantation, vol. 74, no. 9, pp. 1281–1286, 2002.View at: Google Scholar
R. M. Merion, V. B. Ashby, R. A. Wolfe et al., “Deceased-donor characteristics and the survival benefit of kidney transplantation,” Journal of the American Medical Association, vol. 294, no. 21, pp. 2726–2733, 2005.
A. O. Ojo, J. A. Hanson, H.-U. Meier-Kriesche et al., “Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates,” Journal of the American Society of Nephrology, vol. 12, no. 3, pp. 589–597, 2001.